Tài Liệu Đào Tạo Cấp Cứu Cơ Bản

B Y T
CC QUN L KHM CHA BNH

D N TNG CNG CHT LNG NGUN
NHN LC TRONG KHM CHA BNH
TI LIU O TO CP CU C BN
NH XUT BN Y HC
B Y T
CC QUN L KHM, CHA BNH
TI LIU O TO CP CU C BN
NH XUT BN Y HC
H NI - 2014
CH BIN
PGS.TS. Lng Ngc Khu
PGS.TS. ng Quc Tun
THAM GIA BIN SON

TS. Ngc Sn
TS. o Xun C
ThS. Nguyn Trung Nguyn
ThS. Nguyn Thnh
TH K
ThS. Nguyn Th Thanh Ngc
ThS. Nguyn Phng Mai
LI NI U
Theo quy ch cp cu, Hi sc v chng c do B Y t ban hnh km theo
quyt nh 1/2008/Q-BYT ngy 21 thng 1 nm 2008, cc bnh vin tuyn tnh tr
ln s thnh lp khoa Cp cu, cc bnh vin s c khoa cp cu. Do nhu cu v o
to cc bc s c kin thc v cp cu l rt ln v cp bch, nht l hin nay phn ln
cc bc s c tuyn vo cc bnh vin phn ln l bc s a khoa, cha c o to
v chuyn khoa nhng phi lm ngay cc cng vic v chuyn khoa.
Ti liu ny c bin son vi mc ch cung cp cho hc vin cc hiu bit, k
nng c bn, cn thit nht v chn on, x tr cp cu cc tnh hung bnh l thng
gp ti khoa cp cu.
Tm lc ni dung
Ti liu ny cung cp cho hc vin cc hiu bit, k nng trnh chuyn khoa
nh hng v chn on, x tr cp cu cc tnh hung bnh thng gp trong cp cu
v mt s th thut c bn trong cp cu ni khoa v chn thng.
Phm vi p dng ti liu
Ti liu ny c s dng ti cc bnh vin a khoa tnh, thnh trn c nc. Cc
QLKCB c s h tr ca t chc JICA thnh lp nhm chuyn gia son tho
chng trnh v ti liu o to lin tc v Cp cu bao gm cc chuyn gia v Cp cu,
s h tr k thut ca chuyn gia Nht bn t t chc JICA.
y l ti liu bin son ln u nn khng trnh c thiu st. B Y t mong
nhn c nhiu kin ng gp ca cc ng nghip, cc thy c gio v hc vin
ti liu hc tp ny c hon chnh hn cho ln xut bn sau.
TM. BAN BIN TP
Trng ban
PGS.TS. LNG NGC KHU
Cc trng Cc Qun l Khm, cha bnh
MC LC
Ni dung
Trang
A. L THUYT
I. Cp cu ni khoa
1. Nhn nh v kim sot ban u bnh nhn cp cu
2. Cc k thut kim sot ng th
14
3. Chn on v x tr cp cu ban u suy h hp cp
26
4. X tr cp cu sc
34
5. Cp cu ngng tun hon c bn
39
6. Cp cu ngng tun hon nng cao
46
7. Chn on v x tr cp cu nhi mu c tim cp c ST chnh ln
55
II. Cp cu chn thng

8. Cp cu chn thng s no
53
9. Cp cu chn thng ct sng
64
10. Cp cu chn thng ngc
74
11. Cp cu chn thng bng
87
12. Chn on v x tr cp cu ban u sc chn thng ngi ln
93
13. X tr cp cu chn thng xng, phn mm v chi th t ri

III. Cp cu khc
14. X tr cp cu bnh nhn bng
106
15. Nguyn tc chn on, x tr ng c cp
111
16. Vn chuyn bnh nhn cp cu
122
B. THC HNH
1. K thut kim sot ng th
136
2. K thut cp cu ngng tun hon
137
3. K thut vn chuyn bnh nhn
138
4. K thut x tr vt thng xuyn thu
139
5. K thut bt ng xng gy v ct sng
140
PHN I
BI GING L THUYT
Bi 1
NHN NH V KIM SOT BAN U
BNH NHN CP CU
MC TIU
Sau khi hc xong hc vin c kh nng:
1. Trnh by c cc nguyn tc chnh khi tip cn v x tr bnh
nhn cp cu.
2. Trnh by c cc nguyn tc cn tun th trnh cc sai lm.
3. Rn luyn k nng thm khm v cp cu bnh nhn theo 2 bc
(primary v secondary).
4. Rn luyn tc phong khn trng v phn ng theo trnh t.
NI DUNG
1. Khi nim v cp cu
- Cp cu thng c dng ch cc tnh trng bnh ni/ ngoi cn
c nh gi v iu tr ngay. Cc tnh trng cp cu c th l:
+ Nguy kch (khn cp) (critical): bnh nhn c bnh l, tn thng, ri
lon e da tnh mng, nguy c t vong nhanh chng nu khng c can thip
cp cu ngay.
+ Cp cu (emergency): bnh nhn c bnh l, tn thng, ri lon c
th tin trin nng ln nu khng c can thip iu tr nhanh chng
- Cng tc thc hnh cp cu c nhim v nh gi, x tr v iu tr cho
cc bnh nhn c bnh l/tn thng/ri lon cp cu.
2. Cc c th ca cp cu
2.1. Rt nhiu kh khn, thch thc:
- Hn ch v thi gian: tnh cht bnh l cp cu din bin cp tnh v c
th nng ln nhanh chng, do vy i hi cng tc cp cu phi rt khn trng
trong thu thp thng tin, nh gi v a ra chn on, x tr v can thip cp
cu; Bn thn bnh nhn v gia nh cng lo lng v c xu hng i hi thc
hin n tip v cp cu tht nhanh.
- Cn nh gi nhanh v ra quyt nh vi lng thng tin hn ch, cha
y : do i hi phi c quyt nh chn on v x tr nhanh chng ngay sau
khi tip cn bnh nhn (ngoi bnh vin hoc trong bnh vin ti khoa cp cu)
cho nn ngi bc s v y t cp cu thng phi a ra chn on v quyt nh
x tr, chm sc da vo cc thng tin ban u s b, cha y . y l mt
thch thc thc s khi phi a ra cc quyt nh nhiu khi mang tnh cht sng
cn cho tnh mng hoc mt phn c th ca bnh nhn trong khong thi gian
ngn v cha c thng tin y .
- Khng gian v mi trng lm vic: Mi trng lm vic ti khoa cp
cu lun c nhiu p lc khng k p lc v thi gian: khng gian lm vic
thng nm ngay gn cng bnh vin, khng gian m thng thng thng vi
bn ngoi, ng bnh nhn, ng ngi thn ca bnh nhn v c th cn nhiu
i tng khc, dng ngi di chuyn va ng va nhanh (bnh nhn, ngi
than ca bnh nhn, nhn vin) nn d c ln xn, nhiu ting n v kh

kim sot trt t, v sinh v an ninh.
- Trong cp cu trc khi n vin, nhn vin y t c th phi lm vic ngoi
tri, trong mi trng sinh hot khng c h tr v y t, thi tit c th khng thun
li, i khi c th nguy him ngay c cho nhn vin y t (chy n, hin trng tai
nn giao thng)
- Nhiu lo lng v d b phn tm: Ngi nhn vin y t c th phi quan
tm gii quyt nhiu vic khc nhau: tip nhn giy t, th tc hnh chnh, trt
t, phn lung bnh nhnNhiu khi cc mi bn tm ny lm ngi nhn vin
y t kh tp trung vo cng tc chuyn mn cu cha ngi bnh. Cc p lc
cng vic cng nh cc p lc t pha bnh nhn v ngi thn ca bnh nhn
cng c th lm cc nhn vin y t gp kh khn m bo tun th cc quy
trnh v tiu ch cp cu.
- Nhn vin y t c nguy c b e da v tinh thn v bo lc n t cc bnh
nhn kch ng, hung hn, t gia nh v ngi thn ang b mt bnh tnh
2.2. Khng nht thit ch quan tm tm chn on c iu tr m a
phn trng hp yu cu cp thit li l suy ngh xc nhn hoc loi tr cc
bnh l/ri lon nng e da tnh mng hoc e da b phn/chi ca bnh nhn.
2.3. Nhn nh v phn ng c th phi tin hnh song song nhiu quy
trnh (v d va cp cu va hi, va khm), cn phng php thm khm v
nh gi tun t, ln lt tng quy trnh c th li khng ph hp v nhiu khi
l qu chm tr i vi yu cu cp cu.
2.4. Nguy c b qu ti, hu qu l d c bnh nhn b b st (ra vin
m cha c xem):
Lng bnh nhn n cp cu rt thay i theo thi im trong ngy,
gia cc ngy trong tun, gia cc mav rt kh d on chnh xc c
lng bnh nhn n cp cu. Trn thc t l thng xuyn c cc thi im
cc khoa cp cu b qu ti bnh nhn v qu ti cng vic. Khi mt khoa cp
cu b qu ti ln n 140% cng sut th s c nguy c b st bnh nhn v sai
st (bnh nhn khng c cp cu kp thi, c bnh nhn ra vin m cha
c thm khm y )
2.5. Tnh u tin cp cu (gia cc bnh nhn; gia cc ng tc, can
thip, chm sc) m khng phi theo th t thng thng:
Do c nhiu thi im b qu ti nn cc khoa cp cu s phi trin khai
quy trnh phn loi bnh nhn v cc nhn vin cp cu s phi rn luyn k
nng phn loi bnh nhn v phn loi cc cng vic, k thut can thip cp cu
cho ph hp vi yu cu u tin cp cu. Phn ng x l cp cu theo tnh u
tin cp cu (bnh nhn no cn cp cu hn th c khm trc, can thip
no cp thit hn th u tin thc hin trc) gip m bo cc bnh nhn
c tip cn cp cu kp thi tng ng vi tnh trng v yu cu cp cu ca
tng bnh nhn.
2.6. Phi tip cn v sp xp gii quyt khi c bnh nhn t vong
Ti khoa cp cu, nhn vin y t thng xuyn phi tip nhn, cp cu v
gii quyt cc vic lin quan n bnh nhn ngng tun hon v t vong. Khi c
bnh nhn t vong, ngi bc s cp cu phi gii quyt nhiu vic: xc nhn
t vong, thng bo v chun b tm l cho ngi than ca bnh nhn t
vongng thi ngi bc s cng s lun phi t ra cc cu hi v tm cu
tr li: ti sao bnh nhn t vong? Bnh nhn t vong c nguy c ly bnh cho
ngi khc (nhn vin y t, gia nh v ngi thn).
3. Cc nguyn tc chnh khi tip nhn v x tr bnh nhn cp cu

- Mt bc s cp cu, y t cp cu ang trong ca lm vic cn m bo
bao qut kim sot c bnh phng/khu vc v tt c cc bnh nhn m mnh
ph trch. iu i hi ngi nhn vin y t phi rn luyn k nng quan st
nhanh, phng php t chc lm vic hp l v bit tit kim cng nh phn
phi sc lc m bo c ca trc.
- Mt trong cc nhim v kh khn ca bc s cp cu l phi ra cc
quyt nh, nht l khi cc quyt nh thng rt quan trng n bnh tt,
din bin v tnh mng ca bnh nhn. Cc quyt nh iu m cc bc s cp
cu thng phi i mt:
Triage: bnh nhn no cn c thm khm trc?
Cn cc can thip iu tr no n nh bnh nhn?
Cc thng tin no cn cho chn on?
Cn cc iu tr cp cu no?
Bnh nhn c cn nhp vin khng? Hay c th ra vin?
Thng bo cho bnh nhn v cho gia nh ngi thn nh th no?
- Khi tip cn mt bnh nhn cp cu cn tun th cc nguyn tc nht
nh m bo ra c cc quyt nh nhanh, kp thi v chnh xc nht c
th, khng b st cc cp cu, bnh l nguy him.
3.1. Phn loi u tin
- Khi tip nhn mt bnh nhn cp cu, ngi nhn vin y t trc ht
cn xc nh xem bnh nhn c nguy c t vong hin hin khng? Nu khng
c nguy c t vong r rng th cu hi tip theo l bnh nhn c g bt n cn
can thip ngay khng?
- Cc bnh nhn vo cp cu cn c phn loi theo cc mc u tin
c tip nhn cp cu cho ph hp. C nhiu bng phn loi khc nhau,
nhiu mc phn loi khc nhau.
- Trn thc t th im quan trng nht l phi xc nh xem bnh nhn
thuc loi no trong s 3 tnh trng sau:
+ Nguy kch (khn cp) (critical): bnh nhn c bnh l, tn thng, ri
lon e da tnh mng, nguy c t vong nhanh chng nu khng c can thip
cp cu ngay. Cc bnh nhn nguy kch cn c tp trung cp cu ngay, c th
phi huy ng thm c cc nhn vin khc cng n tham gia cp cu.
+ Cp cu (emergency): bnh nhn c bnh l, tn thng, ri lon c
th tin trin nng ln nu khng c can thip iu tr nhanh chng. Cc bnh
nhn cp cu cn c tp trung cp cu nhanh chng v theo di st sao, bnh
nhn cn c t trong tm mt cnh gii theo di ca nhn vin y t.
+ Khng cp cu: bnh nhn c cc bnh l, tn thng, ri lon m t c
kh nng tin trin nng, e da tnh mng. Cc bnh nhn khng cp cu c
th ch khm ln lt sau khi cc bnh nhn nguy kch/cp cu c tip
nhn v tm n nh.
3.2. n nh bnh nhn trc khi tp trung vo thm khm chi tit:
- Cn tip cn bnh nhn cp cu theo trnh t va m bo n nh bnh
nhn va m bo thm khm c y , khng b st tn thng.
- Thm khm cn tin hnh qua 2 bc (2 cp) tun t (primary survey
v secondary survey)
-Bc 1 (primary survey): nhn nh v kim sot n nh cc chc nng sng

- Mc tiu l tm cc ri lon/tn thng e da cc chc nng sng v thc
hin ngay cc can thip cn thit m bo n nh cc chc nng sng.
+ Tp trung vo nh gi v kim sot tun t ABCD (ng th, h hp,
tun hon, thn kinh).
+ Nhanh chng xc nh cc tn thng/ri lon quan trng lm nh
hng cc chc nng sng v c th x tr c ngay: trn kh mng phi p
lc, vt thng mch mu, p tim cp do trn dch/mu mng ngoi tim, ri
lon toan/kim mu nng, ri lon kali mu, h ng mu
+ Thc hin ngay cc iu tr, th thut v can thip cp cu n nh
cc chc nng sng: khai thng ng th, t NKQ, bp bng, th xy, t
ng truyn tnh mch, bi ph th tch, cm mu, chc mng phi, chc dch
mng ngoi tim, sc in chuyn nhp nhanh
- Cc thng tin v tin s, bnh s, thuc ang dng, xt nghim nhanh
c th rt c ch cho cc quyt nh x tr, tuy nhin khng nn mt nhiu thi
gian vo hi, thm khm, lm xt nghim/thm d v khng v hi, thm khm,
lm xt nghim/thm d m lm chm tr qu trnh nh gi v kim sot cc
chc nng sng.
Bc 2 (secondary survey): thm khm mt cch h thng v chi tit theo trnh
t
- Mc tiu l nh gi y cc tn thng/ri lon/bnh l c k
hoch x tr cp cu v x tr iu tr trit hp l.
- m bo khng b st cc tn thng, du hiu/triu chng cn
tun th nguyn tc v trnh t thm khm:
+ ng cnh bnh nhn thu thp bnh s.
+ Thm khm lm sng mt cch tp trung v lin tc, trnh b ngt
qung.
+Nn thm khm mt cch h thng, tun t t u n chn (u mt c,
ngc, bng, khung chu, chi, lng) v thm khm ht tt c cc h thng c
quan (thn kinh, h hp, tim mch, bng v tiu ha, thn-tit niu, sinh dc, tai
mi hng, mt, rng hm mt).
+ Nn tp trung thm khm k vo cc b phn lin quan n cc l do
chnh lm bnh nhn n cp cu cng nh tp trung vo tm kim cc du hiu
gip cho nh hng chn on.
+ Ch nn lm cc thm d, xt nghim gip loi tr hoc khng nh
chn on, hoc gip nh hng chuyn/nhp vin bnh nhn
3.3. Ra quyt nh v chn on v nh hng x tr: u tin chn
on v x tr cc ri lon/tn thng nguy him v c gng chn on loi tr
cc cp cu.
- Ngi bc s cp cu thng xuyn phi tn dng trit lng thng
tin c, x l hiu qu ti a cc thng tin ny da vo kin thc, k nng v
kinh nghim. Mt trong cc tnh chuyn khoa ca cp cu l x l hiu qu v
nhanh chng a ra c cc quyt nh m ch da vo lng thng tin t i c
c.
- Trong iu kin b p lc v thi gian v thiu thng tin, nn tun th mt
s nguyn tc nht nh c th tin n cc chn on v x tr hp l nht:
+ Chn on nu c th, nu khng c chn on: chn on v x tr cc
ri lon/tn thng nguy him v tp trung vo kim sot hoc loi tr cc cp
cu.
+ a ra cc chn on bnh l cp cu nguy him, chn on nhiu kh

nng nht trc; Ngi bc s nn t duy qua 3 bc:
. Tnh ton v lit k tt c cc kh nng c th
. Sau xc nh cc nguyn nhn/tn thng/ri lon no l nguy c
nng n, nguy him nht v ln k hoch chn on v x tr theo nh hng
ny.
. Xc nh xem liu c cc nguyn nhn/tn thng/ri lon khc cn
phi c x l khng
+ Tp hp cc thng tin xc nhn hoc loi tr chn on bnh cp
cu nguy him trc, ri n cc chn on nhiu kh nng nht
+ Trnh chn on kiu chp c, nn tm chn on theo s cy
chn on (algorithm)
+ iu tr c th gip thm cho chn on: p ng vi iu tr hoc
ngc li khng p ng vi iu tr cng u l cc thng tin tt gip thm
cho nh hng chn on.
+ Ch nn lm cc thm d, xt nghim gip loi tr hoc khng nh
chn on, hoc gip nh hng chuyn/nhp vin bnh nhn
+ Nn s dng cc quy trnh, hng dn x tr, iu tr cp cu tit
tim sc v tr no trong gi trc
+ Nn b ra t nht 2-3 pht tp trung suy ngh cho mi bnh nhn
3.4. nh hng chuyn: vo vin/ra vin hay lu theo di
- Trc mi bnh nhn cp cu, ngi bc s chc chn s phi quyt
nh xem bnh nhn s c b tr ch nh th no: nhp vin hay ra vin hay
lu theo di? Nu nhp vin th cho nhp vo khoa no? Cho nhp vin ngay
hay ch theo di thm?
- Trong nhiu trng hp th quyt nh cho vo vin hay cho ra vin l
mt quyt nh rt kh khn. Nht l khi khng c s thng nht gia ca
bc s v nguyn vng ca bnh nhn/gia nh bnh nhn.
- vic quyt nh kh khn v gim thiu sai st, ri ro, cn tun
theo mt s nguyn tc hoc tr li mt s cu hi:
+ Bnh nhn c cn nm vin khng?
+ Nu cho ra vin: c an ton cho bnh nhn khng v cn theo di
nh th no?
+ bnh nhn lu li theo di thm ti khoa cp cu nu cha c quyt
nh hoc cn phn vn hoc khi bnh nhn/gia nh bnh nhn lo lng
+ Suy ngh cn thn trc khi quyt nh
+ Trnh a ra quyt nh khi ang cng thng hoc ang cu gin: tm
dng li trn tnh vi pht ri sau mi quay li gii quyt tip v quyt nh
3.5. Ch n ca s iu tr/thi gian vng trong cp cu:
- Phn ln cc cp cu c th ci thin tin lng t vong/bnh tt/bin
chng nu c tip cn v can thip sm trong mt gii hn thi gian nht nh
(thi gian vng). Ngi nhn vin cp cu cn rt ch v phn u c th
tip cn v can thip iu tr bnh nhn sm trong khong thi gian ny.
- Mt s v d:
+ Ngng tun hon (NTH) v sc in: Sc in cp cu ph rung tht s
c hiu qu nht nu c thc hin trong vng 5 pht u sau ngng tim. Hi
sinh tim phi kt hp vi sc in sm trong vng 3 n 5 pht u tin sau khi
NTH c th t t l cu sng ln n 50% -75%.
+ Hi chng ng mch vnh cp: ca s thi gian cho dng thuc tiu
si huyt l 12 gi i vi NMCT c ST chnh ln (STEMI).
+ Tc mch no: ca s thi gian cho dng thuc tiu si huyt
(Alteplase) l 3 gi.
+ Sc nhim khun/nhim khun nng: cn cho khng sinh ng tim
trong vng 1 gi, iu tr tch cc sm theo mc tiu trong 6 gi u.
+ Vt thng ng mch/ga r mch: cn can thip lp li ti mu trong
vng 6 gi. Nu mun trn 6 gi th nguy c phi ct ct rt cao.
4. Cc nguyn tc trnh sai lm:
- Trnh ro cn ln nht i vi chn on ng: b nh hng ca chn
on trc
- Trnh b nh hng bi suy ngh ca ngi khc: b nhiu chn on v
nhiu t ngi khc (bias)
- Ch n cc du hiu sng, cc ghi chp ca tuyn trc v ghi chp
ca y t
- Trnh gp h s vo qu sm, khi m cha c chn on r rng: cn
cho bnh nhn vo danh sch cha c chn on hoc chn on cha r rng
v c cnh bo, theo di thch hp
- Thn trng vo cc thi im nguy c cao: khi bnh nhn k ra sm,
khi ng bnh nhn, gi cao im hoc thi im mt mi.
- Thn trng vi nhm bnh nhn nguy c cao: lang thang, nghin ru,
nghin thuc, bo lc, b lm dng, ri lon tm thn
- Thn trng vi bnh nhn quay li: bnh nhn c th c cc vn cp
cu m cha c pht hin hoc cha c x tr ng. Bnh nhn quay li
cng l c hi tt chng ta c th sa cha cc sai st hoc b st trong chn
on v x tr ca ln n cp cu trc.
- Ch n cc chn on quan trng c nguy c cp cu cao (cn ngh
n v loi tr trc): nhi mu c tim cp, tc ng mch phi, tc ng/tnh
mch, xut huyt di nhn, chy mu no bnh nhn ng c, vim mng
no, vim rut tha, cha ngoi t cung, xon tinh hon, chn thng gn hoc
thn kinh
- Thn trng khi thy c chn on t ra trc khng ph hp (khng
tng ng vi du hiu, triu chng ca bnh nhn).
TI LIU THAM KHO
1. V Vn nh: Nguyn l c bn hi sc cp cu. Trong quyn: Hi
sc ni khoa. NXB Y hc 2003.
2. Nguyn t Anh, Nguyn Vn Chi, Phng Nam Lm: Phn loi bnh nhn
cp cu theo mc u tin. Tp ch lm sng bnh vin Bch mai, 2004
3. Russell Jones T. Approach to the Emergency Department Patient. In:
Current D & T Emergency Medicine, 2008.
CU HI LNG GI
Cu 1: Cc tiu ch nh gi bnh nhn cp cu l

A. Du hiu sinh tn
B. c im hnh thi tn thng

C. Mc nng ca bnh
D. Kh nng i li ca bnh nhn
E. Tt c cc tiu ch trn
Cu 2: Trn hin trng v tai nn sp nh cao tng c 1 nn nhn trong
tnh trng tnh, t mu di da u, gy xng i kn, au bng vng mng
sn phi, mch nhanh nh 120 ln/pht huyt p 70/40 mmHg. Hy chn
loi bin eo cho nn nhn:
A. en
B.
C. Vng
D. Xanh
Cu 3: Mt bnh nhn nam 65 tui vo vin v au ngc khm thy
bnh nhn tnh, au d di vng ngc tri, nhp tim 120ln/ pht, huyt p
90/60 mmHg. Hy phn nhm bnh nhn:
A. Cp cu khn cp
B. Nng - cn c nh gi y
C. Nhm cn theo di pht hin tnh trng cp cu sp xy ra
D. Khng c tnh trng cp cu
Cu 4. Mt bnh nhn n 50 tui vo vin v nn mu ln t mu cc
2 ln km i ngoi phn en khm bnh nhn tnh, nim mc nht, khng tip
tc nn mu mch 110ln/ pht, huyt p 100/70mmHg, bng mm khng
phn ng. Hy phn nhm bnh nhn:
A. Cp cu khn cp
B. Nng - cn c nh gi y
C. Nhm cn theo di pht hin tnh trng cp cu sp xy ra d) Khng
c tnh trng cp cu
Bi 2
CC K THUT KIM SOT NG TH
MC TIU
1. K tn c nhng ri lon gy tc nghn ng th thng gp.
2. Trnh by c cch x tr tc nghn ng th.
NI DUNG
1. i cng
Khai thng ng th l mt th thut cp cu rt quan trong i vi cc
thy thuc cp cu nhm m bo xy v thng kh y cho bnh nhn. Cc
im chnh ca chm sc ng th l bo v ng th, gii phng tc nghn,
v k thut ht m gii.
Cc th thut khai thng ng th c th rt n gin nh thay i t
th u bnh nhn (k thut nga u nng cm, n gi hm). Khai thng
ng th l mt u tin u tin. Sau tin hnh thng kh ming - ming,
ming - mask, hoc bng ambu. Cui cng l cc bin php bo v ng th
nh canuyn hng ming, t ni kh qun, hoc m kh qun
Cc k thut t ni kh qun (ng mi, ng ming), ni kh qun
theo trnh t nhanh, m kh qun qua mng nhn gip, m kh qun qua da c
trnh by chi tit trong cc bi ring
2. Nguyn nhn gy tc nghn ng th
2.1. Nguyn nhn ni sinh
- Do sp cc t chc phn mm vng hng ming (gim trng lc c,
gy xng hm)
- Ph thanh qun/co tht thanh qun
- Vim sn np thanh qun cp, vim thanh qun cp, bch hu thanh
qun
- Lit dy thanh m hai bn
- ng gy ph nim mc hng v kh qun, thng do phn ng d ng
khi b ong t, khng sinh hoc cc thuc h huyt p (c ch men chuyn)
- Chn thng thanh qun, khi u thanh qun
2.2. Nguyn nhn ngoi sinh
- Ph thanh qun
- m vng hu hng
- Khi mu t (do ri lon ng mu, chn thng, phu thut)
- U tuyn gip
- U hch
- U hoc d vt thc qun
2.3. Di vt
- Thc n
- chi vi tr em hoc bt k vt g vi cc ngi bnh sa st tr tu
hoc ngi bnh tm thn
3. Cc k thut khai thng ng th
3.1. T th bnh nhn

* Khi bnh nhn trong tnh trng khng p ng (bao gm ngng tun hon)
- Nhanh chng pht hin chn thng c hoc mt nu c chn thng
ct sng c c t th nga trung gian.
- Nu bnh nhn ang nm nghing hoc sp th dng k thut lt khc
g (lt ng thi c u, thn v chn tay cng lc) a bnh nhn v t
th nm nga.
- M ng th bng mt trong hai cch: nga u / nhc cm nu khng
nghi ng c chn thng ct sng c hoc n gi hm: ch yu do nhn vin y
t c hun luyn thc hin (nu nghi ng c chn thng ct sng c).
- Mt nguyn nhn thng gp nht gy tc nghn ng th l tt li,
ch p dng mt trong hai cch trn c th ko li v pha trc v m
thng ng th (Hnh 4).
Hnh 4. K thut nga u nhc cm: (A) Tc nghn ng th do tt li; (B)

ng th thng khi thc hin k thut.
Hnh 5. K thut n gi hm
* Cc trng hp khc: Bnh nhn suy h hp, ph no, TBMN: t th

fowler. Bnh nhn ph phi cp : ngi thng chn
3.2. X tr tc nghn ng th
Vic pht hin sm tc nghn ng th c tnh quyt nh. Cc d vt c
th gy tc nghn ng th mt phn hoc hon ton :
- Tc nghn mt phn:
+ Trao i kh c th gn bnh thng, bnh nhn vn tnh v ho c,
cn ng vin bnh nhn t lm sch ng th bng cch ho.
+ Nu vn cn tc nghn, trao i kh xu i, bnh nhn ho khng hiu
qu kh th tng ln, tm th cn can thip gp.
- Tc nghn hon ton :
+ Bnh nhn khng th ni, ho, th ; hn m v cn c cp cu ngay.
Nu cc c gng iu chnh t th bnh nhn tht bi hoc thy c d vt
ming, hu th p dng cc bin php sau :
Hnh 6. Du hiu kinh in ca d vt ng th

3.2.1. p bng (nghim php Heimlich)
p vo vng thng v nhanh lm y c honh ln trn gy tng p lc lng
ngc v to mt lung kh mnh tng d vt ra khi ng th, tng t nh ho:
- Nu bnh nhn ang ngi hoc ng : ng sau bnh nhn v dng cnh
tay m eo bnh nhn, mt bn tay nm li, ngn ci trn ng gia, t ln
bng hi trn rn, di mi c. Bn tay kia m ln bn tay nm v dng ng
tc git ( p) ln trn v ra sau mt cch tht nhanh v dt khot lp li ng tc
ti khi gii phng c tc nghn hoc tri gic bnh nhn xu i.
- Khi bnh nhn hn m: t bnh nhn nm nga, mt nga ln trn, nu
nn u bnh nhn nghing mt bn v lau ming. Ngi cp cu qu gi
hai bn hng bnh nhn, t mt ci bn tay ln bng gia rn v mi c,
bn tay kia p ln trn, a ngi ra pha trc p nhanh ln pha trn, lm li
nu cn.
- Khi ch mt ngi cp cu v phi p tim, h hp nhn to th qu gi
mt bn cnh hng bnh nhn d di chuyn v dng tay p nh trn. Nu c
2 ngi mt ngi h hp nhn to v p tim, mt ngi lm nghim php.
- Nu ch c mt mnh nn nhn: T p bng bng cch n nm tay ln

bng hoc p bng vo cc b mt chc nh bn ra, lng gh, mt bn, v.v...
Hnh 7. Th thut Heimlich khi bnh nhn tnh
Hnh 8. Th thut Heimlich khi bnh nhn hn m

Sau mi t p bng : Dng 2 n 3 ngn tay mc khoang ming kim
tra. Sau khi ly c d vt h hp li cho bnh nhn, nu c kt qu nh gi
h hp, tun hon v thc hin cc can thip thch hp. Nu khng th h hp
c cho bnh nhn lp li qu trnh: p bng, kim tra ng th v h hp
nhn to, nhc li ti khi gii phng c ng th v h hp nhn to c
Hnh 9: K thut ly b d vt
3.2.2. V lng v p ngc: V nghim php Heimlich c th d dng gy
chn thng bng khi dng cho tr nh, kt hp v lng v p ngc cc i
tng ny loi tr d vt. Ch ng tc v lng c th tng c d vt,
nu khng c hiu qu th ni tip bng p ngc, sau kim tra ng th.
- t tr nh nm trn tay t th sp dc theo trc ca tay v u tr thp.
- Dng phn phng ca bn tay v nh v nhanh 5 ci ln vng gia hai
xng b vai.
- Nu v lng khng y c d vt ra, lt tr nm nga v p ngc 5 ci.
V tr v cch p nh vi p tim nhng vi nhp chm hn.
- Lm sch ng th gia cc ln v lng - p ngc, quan st khoang
ming dng tay ly bt c d vt no nu nhn thy, khng dng ngn tay a
su ly d vt.
Hnh 10. K thut v lng (A) p ngc (B) tr nh

* nh gi hiu qu:
- Sau mi ng tc lm sch ng th, xc nh theo d vt c tng
ra cha v ng th c gii phng cha, nu cha c lp li trnh t
cc ng tc thch hp ti khi thnh cng.
- Loi tr d vt thnh cng khi thy : (1) thy chc chn d vt c tng
ra (2) Bnh nhn th r v ni c (3) Bnh nhn tnh hn (4) mu da bnh
nhn tr v bnh thng.
- Nu cc ng tc ny c lm lin tc khng c hiu qu th thc hin
cc bin php khc mnh m hn nu c: Dng n soi thanh qun v ly d vt
bng kp Margill, m kh qun qua mng nhn gip, m kh qun qua da. Cc
k thut ny l nng cao, i hi cc nhn vin c o to c bit tin hnh.
4. Cc k thut bo v ng th
4.1. t Canuyn hu
* Mc ch :
- Gip duy tr s thng thong ca ng th v thng kh y , t
bit khi dng bng Ambu v mask. Canuyn t ng cng gip ht m di d
dng hn.
- Ch nn c thc hin khi cc bin php c bn h tr cc chc nng
sng c thc hin.
- Dng c ny lm thng thong ng th bng cch tch li ra khi
thnh hng.
* Dng c :
- Canuyn: c 2 loi : canuyn ming hu v canuyn mi hu.
- li.
- Cht bi trn canuyn.
4.1.1. Canuyn ming hu: c loi Guedel v Berman vi cc c khc
nhau.
- Chn c thch hp bng cch t u ngoi ca canuyn ngang gc
ming bnh nhn, nu u trong canuyn ti gc hm l ph hp.
- Canuyn t ng khi: u trong nm gc li v trn np thanh mn,
mp u ngoi ca canun bn ngoi cung rng. C 2 k thut t:
+ Nhc hm lm tch li ra khi thnh sau hng, xoay canuyn 1800
trc khi t, khi u canuyn chm hm ch cng th xoay tr li 1800 lm cho
b cong ca canun xp theo khoang ming.
+ Dng li n li, canuyn c trt trn li theo cong ca
vm ming.
- Nu t canuyn sai v tr lm y li ra sau gy tc nghn thm do
ngi t cn c hun luyn trc.
- Chng ch nh : Bnh nhn tnh hoc bn m (c th gy khc, nn, co
tht thanh qun), chn thng khoang ming, chn thng xng hm di
hoc phn hp s thuc xng hm trn, tn thng chon ch hoc d vt
ming hng.
Hnh 11. Canuyn ming hng: (A) Loi Guedel (B) Loi Connel; (C) v tr
4.1.2. Canuyn mi hu
- Ging Canuyn ming hng ch tch li ra khi thnh sau hng
nhng khc l canuyn ny c t qua mi to mt con ng t l mi ngoi
n gc li.
- Ch nh khi khng t c canuyn ming hu, chng ch nh khi c
chn thng hoc tn thng chon ch, d vt vng mi, tr nh (do l mi
nh).
- C nhiu c khc nhau nhng quan trng l chiu di ca canuyn.
Chiu di thch hp tng xng vi khong cch t di tai ti chn cnh mi.
Cch t: Nga nh u v pha sau, bi trn canuyn, a canuyn thng
gc vi bnh din ca mt bnh nhn, t t tin canuyn qua ca mi, m bo
mt vt ca canuyn hng v pha vch mi, nu thy a vo kh c th xoay
nh, nu vn kh rt c th do vo vch mi th t l mi bn kia hoc dng

canun c nh hn. t xong c th kim tra v tr bng cch dng li
nhn. khng cn c nh canuyn thm.
Hnh 12: Canuyn mi-hng: (A) Cc c khc nhau; (B) V tr

4.2. Mt n thanh qun
- Mt n thanh qun l mt loi ng th c nh vng chc hn so vi
mt n mi ming nhng km hn so vi ni kh qun.
- Mt n thanh qun thng c sn xut di dng ng silicon (hoc
nha). Phn cuff (mt n thanh qun) c ni vi bng cuff. Nu t ng v
tr th 3 l m s hng thng vo thanh qun. i vi ngi ln thng dng
c s 4, s 1 cho tr s sinh hoc tr < 6,5 kg; s 2 cho tr t 6,5-20 kg; s 3
cho tr > 30 kg.
- Nn dng mt n thanh qun cho cc bnh nhn hn m. T th u
nga. Cho bnh nhn h ming v u ca cuff p st vo vm hng. y mt
n vo su cho n khi thy cm gic vng. Mt n c t ng khi sau khi
bm cuff thy lung hi th ca bnh nhn pht ln.
- Chng ch nh: chn thng ct sng c nn bnh nhn khng n
c c, bnh nhn khng h c ming, chn thng hu hng, nhng bnh
nhn c nguy c sc cao, v khi cn phi duy tr ng th ko di.
Hnh 13. Mt n thanh qun
Hnh 14. V tr mt n thanh qun

4.3. Cc bin php khc: t ni kh qun, m kh qun, chc, m mng
nhn gip.
TI LIU THAM KHO
Current Emergency Diagnosis & Treatment, 5th Edition. The McGrawHill Companies 2004.
CU HI LNG GI
Cu 1: T th hp l lm thng thong ng h hp bnh nhn khng
c chn thng c mt l:
A. Bnh nhn nm nga, c t th trung gian.
B. Bnh nhn nm nga, c n
C. Bnh nhn nm u cao 30
D. C 3 t th trn u c
Cu 2: Mt bnh nhn nghi ng sc phi d vt, vo vin trong tnh trng
tnh, kh th, tm nh. Thi x tr cn lm trc tin l:
A. Chuyn ngay bnh nhn ln tuyn chuyn khoa soi v ly d vt
B. Bp bng v dt ni kh qun
C. Lm cc nghim php tng d vt ra ngoi
D. bnh nhn nm nga, c n v th oxy
Cu 3: Mt BN vo vin v suy h hp kh th thanh qun, BN c
chn on U h hng-thanh qun. Cc bin php cp cu no sau y l ng:
A. Bp bng c Oxy.
B. Bp bng v t ni kh qun
C. Bp bng v m mng nhn gip
D. Bp bng v m kh qun cp cu
Cu 4: Mt BN vo vin v tai nn giao thng c CT s no, v xng

hm. BN c du hiu suy h hp. Thi x tr no sau y l ng:
A. Cho BN th Oxy v chuyn BN n c s chuyn khoa
B. Cho BN th Oxy v chun b t NKQ
C. Tin hnh m mng nhn gip
D. Tin hnh m kh qun cp cu
Bi 3
CHN ON V X TR CP CU BAN U SUY H HP CP
MC TIU
1. Trnh by c cc nguyn nhn suy h hp thng gp.
2. Nhn bit c kh th v nh hng chn on c mt s nguyn
nhn chnh.
NI DUNG
1. i cng
Suy h hp cp l mt cp cu ni khoa, xy ra khi h thng h hp
khng th p ng c nhu cu chuyn ha ca c th
C dng suy h hp: thiu xy mu, tng CO2 mu v h hp
- Thiu xy mu khi PaO2 50-60mmHg
- Tng CO2 mu khi PaCO2 50 mmHg km theo tnh trng toan mu
pH < 7,36
- Th hn hp l va c gim xy ha mu v tng CO2 mu l dng suy
h hp hay gp trn bnh nhn nng
Suy h hp cp c th xy ra trn mt bnh nhn cha c bnh phi t trc
hoc trn bnh nhn c suy h hp mn tnh
2. Chn on
2.1. Chn on xc nh
- Kh th:
+ L triu chng bo hiu quan trng v nhy
+ Kh th nhanh (> 25 ln/ pht) hoc chm ( < 12 ln/ pht) hoc lon
nhp th (Kussmaul, Cheyne - Stockes ... ), bin th nhanh hoc gim
- Tm: Xut hin khi Hb kh > 5g/ dL, l biu hin ca suy h hp nng
+ Sm: tm quanh mi, mi, u chi
+ Nng, mun: tm lan rng ra ton thn
+ Khng c tm hoc tm xut hin mun nu ng c kh CO
- V m hi
- Ri lon tim mch:
+ Mch nhanh, c th ri lon nhp (rung nh, cn nhp nhanh trn tht,
rung tht... )
+ Huyt p tng, nu nng c th tt huyt p
+ Thng kt hp triu chng suy h hp v suy tun hon. Thc t cn
phn bit suy h hp l nguyn nhn hay hu qu
- Ri lon thn kinh v thc: l triu chng nng ca SHH
+Nh: lo lng, ht hong, tht iu
+Nng: vt v hoc ng g, l , hn m, co git
Lu :
+ Cc du hiu v triu chng lm sng c th ch xut hin khi suy h
hp nng, khi c cc ri lon trao i kh nng n v nguy him. Triu chng
th nhanh, mch nhanh, tng huyt p c th ch xut hin khi SaO2 gim rt
thp < 70-80%. Tm c th ch xut hin khi PaO2 < 45 mmHg, c bit khi
bnh nhn b thiu mu
+ Cc du hiu v triu chng lm sng ca suy h hp l khng c hiu, c
th cng xut hin trong cc trng hp khng c suy h hp
2.2. Chn on mc
Bng 1: phn loi mc suy h hp
Yu t
TRUNG
BNH
NNG
NGUY KCH
Glasgo
w
15
13 - 15
< 13, l ,
hn m
Mch
100 - 120
120 - 140
>140
Nhp
th
25 - 30
30 - 40
> 40 hoc <

10
Ni
Cu di
Cu ngn
Tm
++
+++
V m
hi
++
+++
HA
bnh
thng
tng
gim
pH
7,35
7,45
PaO2
> 60
55 - 60
< 55
PaCO2
45 - 55
55 - 60
> 60
7,25
7,35
< 7,25
2.3. Chn on nguyn nhn

- nh hng chn on:
Hi tin s bnh: hen ph qun, COPD, bnh l tim mch...
c im lm sng:
+ Co ko c h hp: ting rt, kh th thanh qun, ran rt, co tht ph
qun
+ Bin th yu (nhc c, mt c), mnh (toan chuyn ha)
+ Cch xut hin:
t ngt: d vt, nang, trn kh mng phi.
Nhanh: OAP, hen ph qun, vim phi...
T t: u phi, trn dch mng phi, suy tim mt b...
+ au ngc: trn kh mng phi, nhi mu phi, vim mng phi, nhi
mu c tim
+ St (nhim trng): vim phi, vim ph qun...
Thm khm: cn khm k v h hp, tim mch, thn kinh
+ Thm khm k phi:
Ran m, ran rt.
Hi chng 3 gim, ng c, tam chng ca trn kh mng phi
+ Thm khm tim mch: du hiu v triu chng suy tim, bnh tim...
+ Thm khm thn kinh: thc, triu chng lit c h hp...
Cc xt nghim c bn:
+ XQ phi: rt c ngha trong nh hng chn on. Tuy nhin cn n
nh tnh trng bnh nhn trc khi a bnh nhn i chp phim. Nhiu bnh l
c biu hin triu chng trn X quang phi. Tuy nhin c mt s bnh l
thng khng c triu chng X quang r: nhi mu phi, hen ph qun, tc
ng h hp trn, c ch h hp hoc lit h hp
+ Kh mu ng mch: rt cn thit cho chn on xc nh suy h hp,
phn loi suy h hp v nh gi mc nng ca suy h hp. Tuy nhin khng
nn v lm xt nghim kh mu ng mch m lm chm tr cc can thip v x
tr cp cu cho bnh nhn.
+ in tim: gip chn on mt s bnh tim v tm cc du hiu in tim
ca bnh l phi, cc ri lon nhp tim do suy h hp...
Cc xt nghim khc ty theo trng hp c th v tnh trng nng ca
bnh nhn c cho php khng:
+ Siu m tim
+ Chp nhp nhy phi
+ Chp CT scan phi
+ nh lng D Dimer
- Cc nguyn nhn gy suy h hp thng gp:
+ D vt ng th: thng xut hin t ngt vi triu chng xm nhp,
kh th ra, th c ting rt, co rt v s dng cc c h hp ph. Trng hp tc
nghn nng c th gy ri lon thc, ngng th ngng tim
+ Trn kh mng phi: kh th t ngt xut hin sau mt gng sc hoc
t pht. Nu c try mch phi ngh n trn kh mng phi p lc. Khm lm
sng c th thy mt bn lng ngc cng, gim RRFN v g vang. Cn x tr
dn lu kh cp cu c bit khi c trn kh p lc
+ t cp ca bnh phi tc nghn mn tnh (COPD) c trng bi tng
tit m nhy m, co tht ph qun. c im suy h hp hn hp va c gim
xy mu v tng CO2. Chn on da trn tin s bnh nhn c tin s bnh
phi tc nghn mn tnh, xut hin kh th, ho khc m tng, m c, c th
c st. Khm c th thy c ran rt ran ngy, kh ph thng, s dng cc c h
hp ph
+ Vim phi thng c dng suy h hp do gim xy mu. Chn on
da vo lm sng bnh nhn c st, ho khc m c, kh th, au ngc kiu
mng phi. Khm phi thy c hi chng ng c vng phi vim, ran m,
ran n, ting thi ng. Xt nghim mu c th thy bch cu tng, CRP tng,
procalcitinin v mu lng tng. X quang phi khng nh chn on, nh gi
c mc v gip theo di s tin trin
+ Hi chng suy h hp tin trin (ARDS) l biu hin ca mt p ng
vim h thng do tn thng ti phi hoc cc nguyn nhn ngoi phi. Suy h
hp thiu xy mu nng l hu qu ca tng shunt do cc ph nang b lp y.
Lm sng thy suy h hp tin trin nhanh, gim xy ha mu nng (P/F<200).
X quang phi thy tn thng lan ta hai bn phi
+ Tn thng no do chn thng thng biu hin bng suy h hp c
tng CO2 mu, c th bin chng bi suy h hp c gim xy mu khi c km
sc phi hoc bnh phi mn
+ Suy tim huyt mt b: ch yu l suy h hp gim xy mu, tuy
nhin c th gp th tng CO2 trn cc bnh nhn c bnh phi mn tnh km
theo
3. X tr cp cu
3.1. Nguyn tc x tr cp cu: pht hin ngay tnh trng suy h hp nguy
kch can thip th thut theo trnh t ca dy truyn cp cu ABCD, dng
thuc iu tr, theo di v kim sot tt chc nng sng ca bnh nhn
- Khai thng ng th:
+ C n (dn lu t th)
+ Canuyn Grudel hoc Mayo chng tt li
+ Ht m di, ht ra ph qun
+ T th nm nghing an ton nu c nguy c sc
+ Nghim php Heimlich nu c d vt ng th
+ Ni kh qun (hoc m kh qun): bin php hu hiu khai thng
ng th
- Ch nh t ni kh qun:
Tc nghn ng h hp trn
Mt phn x bo v ng th
Kh nng khc m gim nhiu hoc mt
Thiu oxy mu nng khng p ng th oxy
Cn thng kh nhn to xm nhp
- Kim sot thng kh: Cc trng hp cn h tr thng kh
+ Gim thng kh:
Toan h hp vi pH < 7,25
C nguy c gim thng kh hoc gim thng kh s tin trin nng thm:
PaCO2 tng dn
Th nhanh v c cm gic thiu kh
Lit hoc mt c honh (th bng nghch thng, dung tch sng < 15
ml/kg, p lc ht vo ti a - 30 cmH2O)
+ Thiu oxy mu nng km p ng vi th oxy

3.2. xy liu php
- Nguyn tc: phi m bo xy ha mu SpO2 > 90%
- Cc dng c th
+ Canuyn mi: l dng c c dng xy thp 1 - 5 l/pht. Nng xy
dao ng t 24%-48%. Thch hp cho cc bnh nhn c mc suy h hp
trung bnh, bnh nhn COPD hoc cc nguyn nhn suy h hp khng c shunt
hoc shunt trong phi thp
+ Mt n xy: l dng c to dng thp 5-10 l/pht. Nng xy dao
ng 35%- 60%. Thch hp cho cc bnh nhn suy h hp mc trung bnh
do tn thng mng ph nang mao mch (ALI, ARDS). Thn trng khi dng
cho bnh nhn nn do tng nguy c ht cht nn vo phi
+ Mt n khng th li: l dng c to dng xy thp 8-15 l/pht. Nng
xy cao dao ng mc cao 60%-100% ty thuc vo nhu cu dng ca
bnh nhn v kn ca mt n. Thch hp cho bnh nhn suy h hp mc
nng do tn thng mng ph nang mao mch (ph phi, ALI, ARDS), bnh
nhn vim phi nng. Thn trng khi dng cho bnh nhn nn do tng nguy c
ht cht nn vo phi
+ Mt n venturi: l dng c to xy dng cao, c th p ng c nhu
cu dng ca bnh nhn. Nng xy t 24%- 50%. u im l dng cho
nhng bnh nhn cn nng xy chnh xc (COPD)
3.3. Thng kh nhn to
- Thng kh nhn to khng xm nhp p lc dng: h tr thng kh cho
bnh nhn qua mt n (mi, mi ming, ton b mt)
Ch nh: Suy h hp do ph phi cp huyt ng, t cp ca COPD
v HFQ khi
+ Suy h hp nng c du hiu mt c: th gng sc + TS th >
30/min
+ Toan h hp cp ( pH < 7,25-7,30)
+ Tnh trng oxy ho mu ti i (t l PaO2/FiO2 < 200)
Chng ch nh:
+ Ngng th
+ Tnh trng ni khoa khng n nh (Tt HA hay TMCB c tim
khng kim sot c)
+ Mt kh nng bo v ng th
+ m di qu nhiu
+ Vt v hay khng hp tc
+ Tnh trng bnh nhn khng cho php t mt n hay khng bo m
tnh trng kn kht ca mt n
- Thng kh nhn to xm nhp: khi TKNT khng xm nhp c chng
ch nh hoc tht bi.
3.4. iu tr thuc
- Thuc gin ph qun (cht ch vn 2; thuc khng cholinergic): ch
nh vi suy h hp do c co tht ph qun (COPD, hen ph qun). Nn u tin
dng ng kh dung trc, nu khng p ng th chuyn sang truyn tnh

mch
- Corticoid: ch nh cho cc t cp ca hen ph qun, COPD
- Khng sinh: khi c du hiu ca vim (vim phi, t cp COPD c
bng chng nhim khun)
- Li tiu: suy tim huyt, ph phi cp huyt ng, qu ti th tch
TI LIU THAM KHO

1. Stone CK., Humphries RL: Respiratory Distress. Current diagnosis &
treatment of emergency medicine. 6th edition 2008. Mc Graw Hill Lange, 2008:
181-190
2. Rosen Emergency medicine:
edition, Mosby 2006
Concepts and Clinical Practice, 6th
3. Kaynar AM: Respiratory Failure. www.Emedicine.com. Cp nht:

13/04/2010
CU HI LNG GI
Cu 1: Cc loi suy h hp l:
A. Suy h hp do gim xy ha mu
B. Suy h hp do tng CO2
C. Suy h hp hn hp
D. Tt c cc loi trn
Cu 2: Chn on nguyn nhn suy h hp cp da vo:
A. Hi bnh s y
B. Thm khm lm sng cn thn
C. Chp X quang phi
D. Lm kh mu ng mch
E. Siu m tim
F. Tt c cc trn
Cu 3: X tr suy h hp cp cn:
A. m bo t th cho bnh nhn d chu nht
B. m bo ng th c thng thong
C. m bo thng kh
D. Th xy
E. iu tr nguyn nhn
F. Tt c cc trn
Bi 4
X TR CP CU SC
MC TIU
1. Trnh by c chn on xc nh tnh trng sc, phn loi sc.

2. Nu c nguyn tc x tr cp cu sc.
3. Trnh by c cc bin php x tr cp cu sc.
NI DUNG
1. i cng
Sc l bnh cnh hay gp chnh ca khoa Cp cu v Hi sc. c im sinh
l bnh chnh ca sc l gim ti mu h thng ca ton c th dn ti gim
cung cp oxy cho cc m c th. T dn ti s mt cn bng gia cung cp
v trao i oxy, thiu oxy t bo gy tng chuyn ha ym kh, tng gii phng
ra cc cht trung gian, c t ph t bo, hot ha cc phn ng vim. Ban u
tnh trng thiu oxy ny c th hi phc, nhng rt nhanh chng s khng hi
phc hu qu l cht t bo, tn thng c quan ch, suy a tng v t vong.
Do vy quan trng nht l phi pht hin sm v iu tr kp thi.
2. Chn on
2.1. Triu chng chung ca sc
- Pht hin sm cc du hiu v sc: mch nhanh, tt HA, thiu niu,
thay i v thc, toan chuyn ha, da lnh, v m hi, ni vn tm
- thc ht hong do gim lng mu ln no, c th c cn ngt. giai
on mun c th l m, hn m
- < 40 mmHg so vi HA nn. Biu hin sm hn l tt HA t th.
- Thiu niu: gim lu lng mu ti thn gy gim mc lc cu thn,
giai on sm suy thn chc nng giai on mun gy hoi t ng thn suy thn
thc tn.
- Th nhanh sau do tng chuyn ha hoc do toan chuyn ha
- Da lnh, m do co mch, trong sc nhim khun do gin mch thng
c th c ni vn tm
- Bng chng dn do gim ti mu tng trong bng, thiu mu mc treo
- Toan chuyn ha: do chuyn ha ym kh sinh lactic, v mt kh nng
thanh lc lactate ca gan, thn, cvv.
Cc triu chng nguyn nhn gy sc:
- Sc gim th tch: a chy, mt mu, chn thng
- Sc tim: au ngc, gan to tnh mch c ni, ph chi di, rale phi
- Sc nhim khun: st, th trng nhim trng nhim c, vim phi, p

xe tay chi, nhim trng tit niu, nhim trng trong bng
- Sc phn v nh cc biu hin d ng, tin s dng thuc..vv
- Sc tc nghn: nhi mu phi ln, huyt khi tnh mch su.
2.2. Xt nghim nh gi tnh trng sc
- Kh mu: nh gi tnh trng toan mu
- Acid lactic nh gi tnh trng ti mu m
- Xt nghim nh gi tn thng c quan ch: chc nng gan thn,
ng mu, h hp..vv
3. Phn loi cc loi sc:
Sau khi nhn ra tnh trng sc, phi nhanh chng phn loi v tm
nguyn nhn gy sc.
C 4 loi sc chnh
- Sc gim th tch: gim th tch tun hon (a chy, mt mu,
bng, ..vv) lm gim tin gnh gim cung lng tim, tt HA. C th s phn
ng li bng tng nhp tim, co mch mu duy tr HA ti mu cho nhng
tng quan trng nh no, tim, phi, thn. Triu chng lm sng thng nhp tim
nhanh, nht nht, lnh nht u chi, v m hi, mt nc, tt HA t th.
- Sc tim: gim cung lng tim (NMCT, vim c timvv) gy tt HA,
c th cng phn ng li bng cch co mch, th tch tun hon trong trng
hp ny c th bnh thng hoc tng. Triu chng thng l suy tim nh gan
to tnh mch c ni, ph phi, u chi lnh nht do co mch, au ngc, tim
nghe c ting thi.
- Sc gin mch: gin mch h thng do cc yu t trung gian hot mch,
c t (vd sc nhim khun, sc phn v ..) c th cng phn ng li bng cch
tng nhp tim duy tr HA. Th tch tun hon c th thiu hoc bnh thng.
Triu chng thng l tng nhp tim, gin mch u chi, ni vn tm, th trng
nhim trng nhim c hoc c yu t d ng km tho
- Sc tc nghn: nhi mu phi, hoc p tim cp lm tim khng th tng
mu vo i tun hon. Triu chng ch yu tr tun hon tim phi nh kh
th, gan to tnh mch c ni ph ng thi c gim ti mu u chi.
- Sc giai on mun: Cho d bt k do nguyn nhn g nu mun u
dn ti tnh trng hn m, gim cung lng tim, gin mch, th tch tun hon
gim hoc tng, tn thng a tng, toan chuyn ha v t vong.
Bng 1. Cc c im sinh l ca cc loi sc
Phn loi
sc
C
I
S
V
R
P
V
R
S
v
O
R
A
P
R
V
P
P
A
P
P
a
O
P
Sc
(v
tim
d
NMCT
hay
p
tim)
Sc gim
th tch
(vd mt
mu)
Sc phn
b (vd sc
phn v,
sc nhim
khun)
Sc
tc
nghn (vd
tc
m
phi)
CI: ch s tim
PVR: sc cn mch phi
RAP: p lc nh phi
PAOP: p lc m phi bt, N
bnh thng
SVR: sc cn mch h
thng
SvO2: bo ha oxy tm
pha trn
PAP p lc m phi
4. Cch tip cn bnh nhn sc

- Khi nhn ra bnh nhn sc, phi tin hnh hi sc ngay ng thi tm
hiu hi tin s, khm lm sng tm cc triu chng gi , v lm cc xt
nghim khng nh tnh trng v nguyn nhn gy sc.
- Thm d huyt ng ng vai tr rt quan trng trong chn on, theo
di, v iu tr sc c bit trong nhng trng hp sc hn hp v sc giai
on mun, nhiu yu t nhiu nh hng ti triu chng
+ t catheter tnh mch trung tm: nh gi tin gnh tht phi, gin tip
nh gi tin gnh tht tri.
+ Siu m tim: nh gi chc nng tim, loi tr nhanh p tim cp, cc
my siu m tim hin i cn c th nh gi c cung lng tim.
+ t catheter Swan Ganz hoc PiCCO: nh gi tin gnh tht tri (p
lc mao mch phi bt), o c cung lng tim, o c sc cn mch h
thng (hu gnh). Ring vi PiCCO cn c th o c lng nc trong phi.
5. X tr bnh nhn sc
- n nh chc nng sng: m bo oxy ha mu (th oxy, t NKQ,
TKNT), kim sot ng th v t NKQ sm nu bnh nhn hn m trong tnh
trng sc, t ng truyn tnh mch c ln hoc catheter tnh mch trung tm,
truyn dch theo p lc TMTT, ly mu lm xt nghim: cng thc mu, chc
nng gan thn, cy mu.
- Cc bin php hi sc huyt ng

+ t ng thng TMTT duy tr CVP t 11 ti 16 cmH20 truyn dch
mui ng trng, cao phn t hay mu ty tnh trng v loi sc.
+ Nu HA khng ci thin cn nhc s dng cc thuc tr tim v co mch
Bng 2. C ch tc ng ca cc thuc tr tim v co mch
Loi thuc
Liu
truyn
C
O
MA
P
S
V
R
Noradrenal
ine
0,05-0,5
mcg/kg/ph
t
-/+
++
+
+
+
Dopamine
5-20
mcg/kg/ph
t
++
+
+
Adrenaline
0,05-2
mcg/kg/ph
t
++
++
+
+
+
Phenylephr
ine
2-10
mcg/kg/ph
t
++
+
+
+
Vasopressi
0,04 n
v/pht
+++
+
+
+
2,5-10
mcg/kg/ph
t
++
+
-/+
/
0
I. Co mch
n
II. Co bp c tim
Dobutamin
e
CO: cung lng tim
MAP: HA trung bnh
SVR: sc cn mch h thng

- iu tr c hiu cho tng loi sc
+ Sc gim th tch: b khi lng tun hon, ngn chn ngun
mt, cm mu
+ Sc tim: tr tim, bm bng ngc ng mch ch, t thit b h tr
tht..vv. Can thip mch vnh, dng thuc chng ng, chng ngng tp tiu
cu nu NMCT
+ Sc phn v: dng sm adrenaline nu c ri lon huyt ng, corticoid,
loi tr d nguyn khi c th
+ Sc nhim trng: dng khng sinh sm, loi tr nhim khun, liu
php iu tr sm theo mc tiu
+ Sc tc nghn: chc tho dch mng ngoi tim..vv
TI LIU THAM KHO
Current Emergency Diagnosis & Treatment, 5th Edition. The McGrawHill Companies 2004.
CU HI LNG GI
Cu 1. Cc biu hin lm sng ca bnh nhn sc l (nhiu ng):
A. Bnh nhn l m, mt l, ht hong, c th hn m.
B. Da xanh ti, lnh, m m hi, ni vn tm, u chi lnh, tm
C. Huyt p tt, HA tm thu di 90mm Hg c th thy tnh trng kt
huyt p, mch nhanh nh, th nhanh.
D. Tiu nhiu, kht nhiu.
Cu 2. Cc ng tc cp cu ban u no sau y l ng i vi bnh
nhn sc (nhiu ng):
A. Cho bnh nhn nm u thp nu cn tt huyt p.
B. Th oxy qua xng mi hoc mt n.
C. t ng truyn tnh mch ngoi bin chc chn v truyn dch ngay
D. Mc my theo di lin tc nhp tim, HA, SpO2, nhp th
Cu 3. Bnh nhn vn tip tc nng ln, HA tt, tm. Cc x tr cp cu
tip theo l (nhiu ng) :
A. Cho tng oxy ln 10 lt/pht v bnh nhn tm, th chm, ngng th.
B. Nng cao u v ging bnh nhn kh th.
C. Bp bng qua mt n (mask) c oxy.
D. Chun b v ph gip bc s t ni kh qun.
E. Tm ngng truyn thuc nng huyt p (noradrenalin, dopamine,
dobutamin,..) v nhp tim nhanh.
Cu 4. Theo di st bnh nhn sc nng l (nhiu ng:
A. Theo di mch, huyt p 3 gi/ln .
B. Theo di mch huyt p 20 pht/ln.
C. Theo di nhp th, SpO2 3 gi/ln.
D. Theo di nhp th, SpO2 20 pht/ln
E. Theo di nc tiu 6 gi/ln .
Cu 5. Cc biu hin no sau y ca bnh nhn sc th hin bnh nhn
c chm sc tt (nhiu ng):
A. Bnh nhn tnh to, ton trng chung tt ln
B. Huyt p 75/55 mmHg, mch 135 ln/pht
C. Th 14 ln/pht khng phi th oxy qua xng mi hoc mt n.

D. Nc tiu 20 ml/gi, tng liu truyn thuc nng huyt p
Bi 5
CP CU NGNG TUN HON C BN
MC TIU
1. Nu c cc du hiu chn on xc nh ngng tun hon
2. M t cc bc tin hnh hi sinh tim phi c bn
3. Lit k cc nguyn nhn gy ngng tun hon thng gp v c th iu
tr nhanh chng
NI DUNG
1. i cng
Hi sinh tim phi cn c bt u ngay lp tc sau khi pht hin bnh
nhn ngng tun hon (NTH). Do khong thi gian t khi gi cp cu n khi
kp cp cu c mt cp cu bnh nhn thng trn 5 pht, nn kh nng cu
sng c bnh nhn ngng tim ph thuc ch yu vo kh nng v k nng
cp cu ca kp cp cu ti ch.
Sc in cp cu ph rung tht s c hiu qu nht nu c thc hin
trong vng 5 pht u sau ngng tim. Hi sinh tim phi kt hp vi sc in
sm trong vng 3 n 5 pht u tin sau khi ngng tun hon c th t t l
cu sng ln n 50% -75%.
2. Chn on:
2.1. Chn on xc nh: da vo 3 du hiu: mt thc t ngt,
ngng th, mt mch cnh.
2.2. Chn on phn bit:
Phn bit v tm thu vi rung tht sng nh: cn xem in tim trn t
nht 2 chuyn o
Phn bit phn ly in c vi sc, try mch: cn bt mch 2 v tr tr ln
Phn bit mt mch cnh/mch bn do tc mch: cn bt mch 2 v tr
tr ln
2.3. Chn on nguyn nhn:
Song song vi cp cu hi sinh tim phi c bn, cn nhanh chng tm
kim nguyn nhn gy ngng tun hon gip cp cu c hiu qu v ngn
nga
ti
pht.
Cc nguyn nhn gy ngng tun hon thng gp v c th iu tr nhanh

chng:
11 T
6H
11 T
trong ting Vit
trong ting
Anh
Hypovolemi
a
Hypoxia
trong
ting Vit
Trng c
cp
Tamponad
e tim
Trn kh
mng
Thiu th tch tun

hon
Thiu oxy m
Toan ha mu
Tng / Tt kali
mu
Hydrogen
ion
(acidosis)
Hyper-/
phi p lc
Tc mch
(mch
Hypokalemi
a
vnh,
mch
phi)
Tt h ng
Hypoglycem
Thng
huyt
ia
tch
Thn nhit thp
Hypothermi
a
cho d nh, gi tt l 5T 6H (ting Anh) hay 11 T (ting Vit)
5 T
trong ting
Anh
Toxins
Tamponade
(cardiac)
Tension
pneumothorax
Thrombosis
(coronary and
pulmonary)
Trauma
3. X tr cp cu:
3.1. Nguyn tc chung:
- X tr cp cu ngng tun hon c khi ng ngay t khi pht hin trng
hp nghi ng ngng tun hon. Ngi cp cu va tin hnh chn on, gi ngi
h tr va bt u cc bin php hi sinh tim phi c bn ngay.
- Cn c 1 ngi l ch huy phn cng, t chc cng tc cp cu ng trnh
t v ng b.
- Cn ghi chp cc thng tin cn thit v tin trnh cp cu
- Thit lp khng gian cp cu rng v hn ch ti a cc nhn vin hoc
nhng ngi khng tham gia cp cu vo v lm cn tr cng tc cp cu
3.2. Tin hnh ngay hi sinh tim phi c bn (ABC): ng thi gi h tr
khi pht hin bnh nhn nghi ng b ngng tun hon (khng c ng, khng
phn ng khi lay gi )
3.2.1. Kim sot ng th: t nga u, c n, th thut ko hm
di/nng cm
(jawthrust/chinlift)
3.2.2. Kim sot v h tr tun hon: p tim ngoi lng ngc
Kim tra mch cnh (hoc mch bn) trong vng 10 giy. Nu khng
thy mch: tin hnh p tim ngay.
p tim 1/2 di xng c, ln 1/3-1/2 ngc (4-5 cm vi ngi ln) s
thy mch khi p; tn s 100 ln/pht. Phng chm l p nhanh, p mnh, khng
gin on v ngc phng ln ht sau mi ln p
3.3. Cp cu ti Khoa cp cu:

3.3.1. Nhanh chng ghi in tim v theo di in tim trn my theo di.
Phn loi 3 loi in tim: rung tht/nhp nhanh tht, v tm thu, phn ly in c.
3.3.2. Tin hnh sc in ngay nu l rung tht
My sc in 1 pha: s 360 J; My sc in 2 pha: 120-200 J, sc in
khng ng b
Tin hnh ngay 5 chu k p tim/thi ngt sau mi ln sc in
4. Phng bnh
Ngng tun hon thng xy ra t ngt, khng d on trc c.
Tt c cc nhn vin cp cu, nhn vin y t cu h phi c tp luyn v
chn b sn sng cp cu ngng tun hon. Cc xe cp cu, cc c s cp cu
cn c cc phng tin v thuc cp cu cn thit cho cp cu ngng tun hon.
TI LIU THAM KHO
1. American Heart Association. 2010 AHA Guideline for CPR and EC
2. Circulation. 2010;112 (suppl 4):S1. (trang web:
www.circulationaha.org)
CU HI LNG GI
Cu 1. Lit k 3 du hiu ca ngng tun hon:
A. ....................................................
B..................................................
C...................................................
Cu 2. Chn on ngng tun hon (chn ng):
A. L chn on ca bc s
B. Da vo lm sng
C. Da vo in tim v in tm
D. Tt c cc trn u ng
Cu 3. Nhng cu tr li di y l ng hay sai
STT
N
1
u tin gi to mi ngi n h tr
2
Lm nghim php Heimlichinu nghi ng c
d vthnh
ng
3
Tin
p th
tim sau khi thi ngt 2 ci lin
tip
4
Ngng
p tim khi bp bng d
u
5
Khi c 2 ngi: p tim 5 cinthi ngt 1 ci
6
Ngng 5 giy sau pht u
g kim tra mch
cnh
mch
bn
7
p tim tr em 100 - 120 nhp/pht, ngi ln
80 - in
100 nhp
/pht php hiu qu nht
8
Sc
l phng
ng
Sai
Cu 4: Cch dng Adrenalin trong cp cu NTH (chn 1 ng)

A. 1- 2 mg/ tim TM/ ln cch nhau 3 5 pht
B. 2 mg/ tim TM/ ln cch nhau 3 5 pht c) 1 mg/ tim TM/ ln cch
nhau 3 5 pht d) 1 mg/ tim TM/ ln cch nhau 2 pht
C. Truyn Adrenalin TM lin tc
Bi 6
CP CU NGNG TUN HON NNG CAO
MC TIU
1. Trnh by c phc cp cu nng cao ngng tun hon (NTH).
2. K tn 11 nguyn nhn ch yu cn pht hin trong cp cu NTH.
3. Thc hin c cp cu nng cao NTH trn m hnh, bao gm phi
hp cc k thut cp cu: t ni kh qun (NKQ), bp bng, sc in v dng
thuc theo tnh hung lm sng v in tm .
NI DUNG
1. i cng
Hi sinh tim phi c bn (BLS) gip duy tr dng mu tuy nh nhng v
cng quan trng cho no v tim. Hi sinh tim phi nng cao (ACLS) nhm
kim sot ti mu no v tim tt hn na v nhanh chng ti lp li tun hon
m quan trng nht l tin hnh sc in cng sm cng tt. Sc in cp cu
ph rung tht s c hiu qu nht nu c thc hin trong vng 5 pht u sau
ngng tim. Hi sinh tim phi kt hp vi sc in sm trong vng 3 n 5 pht
u tin sau khi ngng tun hon c th t t l cu sng ln n 50% -75%.
2. Chn on
2.1. Chn on xc nh: da vo 3 du hiu: mt thc t ngt,
ngng th, mt mch cnh.
2.2. Chn on phn bit
- Phn bit v tm thu vi rung tht sng nh: cn xem in tm trn t
nht 2 chuyn o.
- Phn bit phn ly in c vi sc, try mch: cn bt mch 2 v tr tr
ln.
- Phn bit mt mch cnh/mch bn do tc mch: cn bt mch 2 v tr
tr ln.
2.3. Chn on nguyn nhn
Song song vi cp cu hi sinh tim phi, cn nhanh chng tm kim
nguyn nhn gy NTH gip cp cu c hiu qu v ngn nga ti pht. Lu
11 nguyn nhn thng gp v c th iu tr nhanh chng (xem quy trnh cp
cu c bn NTH).
3. X tr
3.1. Nguyn tc chung
- X tr cp cu NTH c khi ng ngay t khi pht hin trng hp
nghi ng NTH.
- Cn c 1 ngi l ch huy phn cng, t chc cng tc cp cu ng
trnh t v ng b.
- Cn ghi chp cc thng tin cn thit v tin trnh cp cu.

- Thit lp khng gian cp cu rng v hn ch ti a cc nhn vin
hoc nhng ngi khng khng tham gia cp cu vo v lm cn tr cng tc
cp cu.
3.2. Tin hnh: tin hnh ngay hi sinh tim phi c bn ng thi gi h
tr khi pht hin bnh nhn nghi ng b NTH (khng c ng, khng phn ng
khi lay gi ) [xem quy tnh cp cu c bn NTH].
3.3. Ghi in tm sm ngay khi c th v sc in ngay nu c ch
nh
3.3.1 Nhanh chng ghi v theo di in tm trn my theo di. Nhn
nh 3 dng in tim: rung tht/nhp nhanh tht, v tm thu, phn ly in c
3.3.2. Rung tht hoc nhp nhanh tht v mch:
- Tin hnh ngay hi sinh tim phi c bn, t NKQ cng sm cng tt
v m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo
di in tm trn my monitor nu c. Nu c lon nhp dng ngay thuc
chng lon nhp thich hp.
- Tin hnh sc in ngay: sc in khng ng b. Sc 360 J (My
sc in 1 pha); 150-200J (My sc in 2 pha); Tin hnh ngay 5 chu k p
tim/thi ngt sau mi ln sc in.
- Cc thuc dng trong x tr rung tht: adrenaline, amiodarone,
Magne sulfate, Lidocaine (xylocaine), Vasopressine, Procainamid.
3.3.3. X tr v tm thu:
- V tm thu l tnh trng hnh nh sng in tm l ng thng
nhng phi kim tra t nht 2 chuyn o khng nhm vi rung tht sng
nh.
- Tin hnh ngay hi snh tim phi c bn, t NKQ cng sm cng tt v
m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo di
in tm trn my monitor nu c. Nu c lon nhp dng ngay thuc chng
lon nhp thch hp.
- nh gi v tm kim tnh trng vn cn dng tun hon nhng yu (gi
phn ly in c ) bng siu m tim nhanh.
- Nhanh chng tim kim cc nguyn nhn gy ra NTH. (Xem quy trnh
cp cu c bn NTH) v x tr theo nguyn nhn.
- Nu c th t ngay to nhp ngoi qua da.
- Cc thuc dng trong x tr v tm thu: adrenalin, atropin.
3.2.4. X tr phn ly in c:
- Phn ly in c l tnh trng c hnh nh sng in tm nhng khng
bt c mch cnh.
- Tin hnh ngay hi sinh tim phi c bn, t NKQ cng sm cng tt v
m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo di
in tm trn my monitor nu c. Nu c lon nhp dng ngay thuc chng
lon nhp thich hp. nh gi v tim kim tnh trng vn cn dng tun hon
nhng yu ( gi phn ly in c ) bng siu m tim nhanh.
- Nhanh chng tim kim cc nguyn nhn gy ra NTH. ( xem quy trnh
cp cu c bn NTH) v x tr theo nguyn nhn.
- Cc thuc dng trong x tr phn ly din c: adrenalin, atropin ( nu
nhp tim chm), natri bicacbonat truyn tnh mch nu c toan ha mu.
4. Phng bnh
NTH thng xy ra t ngt, khng d on trc c. Tt c cc nhn

vin cp cu, nhn vin y t cu h phi c tp luyn v chn b sn sng cp
cu NTH. Cc xe cp cu, cc c s cp cu cn c cc phng tin v thuc
cp cu cn thit cho cp cu NTH.
TI LIU THAM KHO
1. American Heart Association. 2010 AHA Guideline for CPR and ECC.
2. Circulation. 2010;112 (suppl 4):S1. (trang web: www.circulationaha.org)
A-
PHC X TR CP CU NNG CAO

I VI RUNG THT V NHP NHANH THT V MCH
BT U CC BC ABCD CA HI SINH TIM PHI C BN (BLS+ Sc in kh rung)
nh gi p ng ca nn nhn
Khi ng h thng cp cu ngng tim
Gi my kh rung
A: ng th (Airway): p dng cc bin php khai thng ng th
B: H hp (Breathing): Tin hnh 2 nhp thi ngt, mi nhp thi ngt trong vng 1 giy
C: Tun hon (Circulation): p tim ngoi lng ngc: Tin hnh 30 ln p tim/ 2 ln thng kh ti khi chun b song my kh rung
D: Kh rung (Defibrillation): nh gi v tin hnh lm sc in nu c rung tht v nhp nhanh tht v mch, nh
1 ln sc in (360 J vi my sc in monophasic hay 150-200J vi my sc in biphasic)
Rung tht & nhp nhanh tht vn tn ti hay ti pht ?
C nhp trn in tm ?
Kh rung x 1 ln nh sc in
(360J i vi monophasic, 150-200 J i vi biphasic
V tm thu
Cn hot
ng in
song v
mch
Phc hi li tun
hon t nhin ?
nh gi cc du
hiu sinh tn
H tr ng th
H tr h hp
Dng thuc thch
hp x tr HA,
tn s tim v lon
nhp
(a): Cp bng chng:

Cp I - iu tr hay can thip lun c
chp nhn, vi tnh an ton c chng minh
v chc chn c li;
Tin hnh ngay tr li BLS x 2 pht

(30 ln p tim/ 2 ln thng kh)
TIN HNH CC BC ABCD CA ACLS

(Thc hin cc nh gi v iu tr nng cao hn)
A: ng th (Airway): t cannun ng th (vd NKQ) cng sm cng tt
B: H hp (Breathing):
m bo cannun ng th t ng v tr bng khm lm sng v test khng
nh
C nh tt cannun, nn s dng cc thit b c nh cannun ng th c chng
m bo tnh trng oxy ha mu v thng kh c hiu qa
C: Tun hon (Circulation) :
t ng truyn tnh mch
Pht hin nhp tim v theo di trn mn monitor
Dng thuc chng lon nhp thch hp iu tr tnh trng lon nhp (nu c)
D: Chn on phn bit (Diferential diagnosis): Tm kim v x tr nguyn
nhn gy ngng tim c th iu tr c (12 T)
Cp IIa - Chp nhn c, an ton, hiu qu;

iu tr chun hoc can thip c la chn;
Cp IIb - Chp nhn c, an ton, hiu
qu; c coi l iu tr chun, nhng ch l
la chn c xem xt hay can thip thay
th;
Cp III - Khng hiu qu v i khi c hi.
Adrenalin: 1mg tim tnh mch nhanh (hoc 2-2,5 mg bm qua ng NKQ),
tim nhc li 3-5 pht/ln
Hoc Vasopressin: 40U tim tnh mch x 1 liu v dng 1 ln duy nht
Th nh li sc in kh rung
1 x 360 J (hay 200- 250J khi dng my biphasic) trong vng 30-60 giy
Xem xt dng thuc chng lon nhp:
(a)
PHC X TR CP CU NNG CAO I VI

TNH TRNG C HOT NG IN SONG KHNG C MCH
Tnh trng c hot ng in song v mch (Pulseless Electrical Activity [PEA])
(C nhp tim trn mn monitor song khng bt c mch)
PEA bao gm cc loi nhp:
Phn ly in-c (Electromechanical dissociation (EMD)
Gi phn ly in c (Pseudo-EMD)
Cc nhp t tht
Cc nhp thot tht
Nhp chm v tm thu (Bradyasystolic rhythms)
Cc nhp t tht xy ra sau sc in kh rung tim (Postdefibrillation idioventricular rhythms)
Bt u cc bc ABCD ca Hi sinh tim phi c bn (BLS+ Sc in kh rung)

3. Gi my kh rung
C: Tun hon (Circulation): p tim ngoi lng ngc: Tin hnh 30 ln p tim/ 2 ln thng kh (hay thi ngt)
D: Kh rung (Defibrillation): nh gi v nh sc in nu c rung tht v nhp nhanh tht v mch
1.
2.
Tin hnh cc bc ABCD ca ACLS (Thc hin cc nh gi v iu tr nng cao hn)

m bo cannun ng th t ng v tr bng khm lm sng v test khng nh
Pht hin
xnntr)
nguyn
nhn
gp gy tnh trng cn
C nh tt(v
cannun,
s dngcc
cc thit
b c nh canun
ngth-ng
th c chng
m boin
tnh trng oxy
ha mu
thng kh (11T)
c hiu qa
hotng
song
vvmch
t ng truyn tnh mch

nh gi v tm kim tnh trng vn cn dng tun hon d yu (Tnh trng gi phn ly in c)
(a)
D: Chn on phn bit (Diferential diagnosis): Tm kim v x tr nguyn nhn gy ngng tim c th iu tr c
Thiu th tch tun hon

(Truyn dch)
Tc mch vnh hay NMCT cp rng
Thiu xy m (th O2,

th my)
Trn kh mng phi p lc (Chc gim

p mng phi)
Toan ho mu (Truyn
Bicarbonat) (b)
Trn dch mng ngoi tim gy p tim cp

(Chc dch mng tim)
Tng kali mu (CaCl2, vv)

v Tt gim kali mu
(Truyn kali)
Trng c do qu liu thuc hoc do

ung nhm cc thuc nh tricyclic,
digitalis, chn bta giao cm...
Tt h glucose mu
Tc mch phi ln (Phu thut, thuc

tiu huyt khi
Thn nhit thp
Thng tch
Adrenalin: 1 mg tim tnh mch nhanh, dng nhc li 3-5 pht/ln.

Atropin 1 mg tim tnh mch (nu tn s tim chm)
Tim nhc li 3-5 pht/ln nu cn, n khi t tng liu 0,04 mg/kg
PHC X TR CP CU NNG CAO I VI V TM THU

V tm thu
BT U CC BC ABCD CA HI SINH TIM PHI C BN (BLS+ Sc in kh rung)
Gi my kh rung
C: Tun hon (Circulation): p tim ngoi lng ngc: Tin hnh 30 ln p tim/ 2 ln thng kh
Khng nh li chc chn bnh nhn c tnh trng v tm thu
D: Kh rung (Defibrillation): nh gi v tin hnh sc in nu c rung tht v nhp nhanh tht v mch
Tm kim nhanh ngay ti hin trng bng chng cho quyt nh khng cn tin hnh cp cu
(a)
TIN HNH CC BC ABCD CA ACLS (Thc hin cc nh gi v iu tr nng cao hn)

m bo cannun ng th t ng v tr bng khm lm sng v test khng nh
C nh tt cannun, nn s dng cc thit b c nh canun ng th c chng
m bo tnh trng oxy ha mu v thng kh c hiu qa
t ng truyn tnh mch
nh gi v tm kim tnh trng vn cn dng tun hon d yu (Tnh trng gi phn ly in c)
D: Chn on phn bit (Diferential diagnosis): Tm kim v x tr nguyn nhn gy ngng tim c th iu tr c
To nhp qua da (nu c th thc hin c, cn tin hnh ngay)
(b)
Adrenalin 1mg tim nhanh tnh mch (2-2,5mg bm qua ng NKQ)

Tim nhc li 3-5 pht /ln.
(c)
Atropin 1 mg tim tnh mch (hoc 2-2,5 mg bm qua ng NKQ)
Tim nhc li 3-5 pht /ln n khi t ti tng liu 0,04 mg/kg
Tnh trng v tm thu vn tip din

Cn nhc ngng cp cu khi:
Tin hnh cp cu ng nhng khng kt qu
Khng phi l BN b ngt nc hoc h thn nhit
Khng tm thy nguyn nhn c th phc hi hoc khng phi l BN ng c cp
tiu chun ngng cp cu theo phc cp cu ti c s
a): nh gi cc ch s lm sng ch dn khng cn ch nh cp cu (vd

du hiu chng t BN t vong).
b) t my to nhp khng c khuyn co ch nh thng quy
iu tr v tm thu ngoi tr trong cc trng hp c chn lc nh v tm thu
xy ra trong qu trnh lm th thut
c): Adrenalin 1mg tim tnh mch 3-5 pht/ln. Nu khng c hiu
qu, c th dng liu cao hn (ti 0,2 mg/kg) nhng khng c Hi tim
mch M khuyn co.
CU HI LNG GI
Cu 1. Mt bnh nhn b ngng tun hon, ang c p tim v thi ngt.

Sau khi ghi in tim, hnh nh in tim l rung tht. Hy la chn 1 thi x
tr ng:
A. Xylocain 1mg/kg tim tnh mch
B. m vo vng trc tim
C. Sc in ng b 200 J
D. Sc in khng ng b 200 J
Cu 2. Cc iu no sau y l ng trong rung tht:
A. Trn monitor, hnh nh rung tht c th ging vi hnh nh in tim b
nhiu
B. Vn c th s thy mch trong rung tht
C. Tim khng cn tng mu trong rung tht
D. C th iu tr hiu qu rung tht bng sc in
Cu 3. Ri lon nhp tim no hay gp nht trong pht u tin ca ngng
tun hon ngi ln:
A. Nhp hp hi
B. V tm thu
C. Blc nh tht cp 3
D. Rung tht
Cu 4. Cn tin hnh cp cu ngng tun hon khi thy du hiu no sau
y (ch ra mt du hiu ng):
A. Tm ti hoc nht nht
B. Mt mch quay
C. Mt mch cnh
D. Nghe khng thy r ting tim
Bi 7
CHN ON V X TR CP CU NHI MU C TIM CP
C ST CHNH LN
MC TIU
1. Trnh by c cc triu chng v chn on nhi mu c tim cp
c ST chnh ln.
2. Trnh by c cc bin php x tr cp cu nhi mu c tim cp.
NI DUNG
1. i cng
Nhi mu c tim (NMCT) cp l hu qu ca tc t ngt ng mch
vnh. y l mt cp cu tim mch c t l gp ngy cng tng nc ta.
NMCT c th c nhng bin chng nng nh suy tim, ri lon nhp tim, ri
lon dn truyn, hoc cc bin chng c hc, e da tnh mng bnh nhn.
NMCT c ST chnh ln l trng hp bnh nhn c biu hin hi chng
vnh cp v c ST chnh ln trn in tim. Cc trng hp c biu hin hi
chng vnh cp nhng in tim khng c ST chnh ln c th l cn au tht
ngc khng n nh hoc NMCT khng c ST chnh ln.
Mc d c nhiu tin b trong chn on v iu tr, nhng t l t vong
ca NMCT vn cn cao. Hin nay, mt trong nhng vn c quan tm
nht trong iu tr NMCT l thc hin tht sm vic iu tr ti ti mu, bng
can thip hoc bng thuc. Do vic chn on v iu tr NMCT phi
c tin hnh ht sc khn trng.
2. Chn on
2.1. Chn on xc nh
- Triu chng lm sng in hnh l cn au tht ngc: au sau xng c,
lan ln vai v ra tay tri, au ko di v khng ht khi ngm nitroglycerin. Cn
au ko di > 20 pht. Tuy nhin cng c nhng trng hp au ngc khng
in hnh (au vng thng v, au lan ln hm di, hoc ch c cm gic
nng ngc), do cn lm in tim cho tt c nhng ngi nghi ng c NMCT.
- Mi xut hin cc thay i ca ST hoc sng T hoc mi xut

hin bloc nhnh tri:
ST chnh ln (khi khng c bloc nhnh tri hoc dy tht tri) 0,1 mV
2 chuyn o lin tip (tr chuyn o V2,V3); V2, V3: 0,2 mV ngi
40 tui tr ln, 0,25 mV ngi di 40 tui, 0,15 mV n gii.
- Xut hin sng Q bnh l trn in tim.
- Siu m tim: mi xut hin bt thng vn ng vng.
- Tng cc du n sinh hc ca hoi t c tim: troponin, CK/CK-MB.
Chn on xc nh nhi mu c tim da vo: triu chng lm sng c
trng ca thiu mu cc b c tim (cn au ngc) kt hp vi ST chnh ln v
tng du n sinh hc ca hoi t c tim.
2.2. Chn on phn bit
- Vim c tim cp
- Trn dch mng ngoi tim cp
- Bc tch ng mch ch
- Tc ng mch phi
- Cc bnh l ngoi tim: trn kh mng phi, vim ti mt cp, cn au
d dy cp, tro ngc d dy thc qun.
Chn on phn bit ch yu da vo in tim v siu m, trong bc
tch ng mch ch, tc ng mch phi cn chp MS CT chn on.
2.3. Chn on mc nng
nh gi mc nng ca NMCT cp da vo:
2.3.1. S xut hin cc bin chng cp tnh
- Suy tim: nh gi bng Killip
Killip I: khng c biu hin suy tim huyt
Killip II: c ran m 1/3 di 2 phi
Killip III: c ph phi cp
Killip IV: c sc tim
- Ri lon nhp tim.
- Ri lon dn truyn
- Bin chng c hc
2.3.2. Cc bnh l km theo:
- i tho ng
- Suy thn
3. X tr cp cu
3.1. Cc thuc
- c ch ngng tp tiu cu:
+ Aspirin 160 325 mg. Sau duy tr 81 325 mg/ngy.
+ Clopidogrel: bnh nhn 75 tui tr xung dng liu u 300 mg, sau
dng 75 mg/ngy; bnh nhn trn 75 tui dng 75 mg liu u, sau 75
mg/ngy.
- Nitroglycerin tnh mch, ch nh khi huyt p bnh thng, bt u
vi liu 10 g/pht, sau iu chnh theo triu chng. C th thay bng
nitroglycerin ngm di li nu khng c loi truyn tnh mch.
- Morphin sulphat 2 4 mg tim tnh mch nu tnh trng au ngc
khng p ng vi nitrat. C th nhc li sau 5 15 pht nu cha ht au ngc.
- Th oxy 2 4 lt/pht.
- iu tr chng ng:
+ Heparin khng phn on liu u 60 n v/kg tim tnh mch (ti a
4000 n v), sau dng liu 12 n v/kg/gi (ti a 1000 n v/gi), iu
chnh liu duy tr aPTT bnh/chng = 1,5 2,0.
+ Enoxaparin: bnh nhn di 75 tui dng liu u 30 mg tim tnh
mch, sau 15 pht tim di da 1 mg/kg mi 12 gi; bnh nhn 75 tui tr
ln tim di da 0,75 mg/kg mi 12 gi (khng bolus).
- Thuc c ch bta giao cm:
+ Ch nh dng ng ung cho tt c cc bnh nhn tr trng hp c
chng ch nh vi thuc c ch bta.
+ Metoprolol tartrat 25-50 mg ung mi 6 12 gi.
- Thuc c ch men chuyn angiotensin:
+ C th dng cho tt c cc bnh nhn khng c chng ch nh.
+ Captopril 6,25 12,5 mg ung 3 ln/ngy, sau c th tng n 25 50 mg 3 ln/ngy ty theo p ng ca bnh nhn.
- Statin:
+ Dng cho tt c cc bnh nhn khng c chng ch nh.
+ Atorvastatin ung liu cao 80 mg/ngy.
3.2. iu tr ti ti mu
Vic iu tr ti ti mu cn phi c tin hnh rt sm.
3.2.1. Can thip mch vnh:
- Cn tin hnh trong vng 90 pht sau khi xut hin au ngc, nu c s
iu tr c kh nng chp mch vnh v can thip ti ti mu.
- Nu c s iu tr khng c kh nng can thip mch vnh:
+ C th chuyn bnh nhn n c s khc vic can thip mch vnh
thc hin c trong vng 120 pht sau khi bt u au ngc: khn trng
chuyn ngay can thip kp thi.
+ Nu khng c kh nng chuyn i thc hin can thip trong vng
120 pht k t khi au ngc: ch nh iu tr ti ti mu bng thuc tiu si
huyt.
3.2.2. Dng thuc tiu si huyt:
- Thuc tiu si huyt c ch nh trong iu tr NMCT cp trong
trng hp bnh nhn n sm nhng khng th tin hnh c can thip mch
vnh trong vng 120 pht k t khi au ngc.
- Cc chng ch nh tuyt i:
+ Tin s chy mu no
+ Tin s t qu loi thiu mu cc b trong vng 3 thng gn y
+ C khi u c tnh ni s
+ ang b chy mu hoc c c a chy mu
+ Bc tch ng mch ch
+ Tin s chn thng hm mt hoc s no kn trong vng 3 thng gn
y
- Cc chng ch nh tng i:
+ Huyt p > 190/110
+ Tin s t qu loi thiu mu cc b > 3 thng
+ INR > 2
+ Tin s chy mu ni tng trong vng 2 4 tun tr li
+ Sau phu thut ln
+ C thai
+ C ng chc vo cc mch khng th p cm mu
- Ngoi cc tnh hung c nu mc 3.2.1., can thip mch vnh
c u tin p dng hn iu tr tiu fibrin khi:
+ Suy tim huyt nng
+ C sc tim
+ Lon nhp tht khng n nh
+ Bnh nhn n vin mun (sau 3 gi k t khi bt u au ngc)

+ Chn on NMCT khng tht chc chn
- Mt s thuc tiu si huyt:
Tenecteplase (TNK-tPA): tim tnh mch 1 liu ty theo cn nng bnh
nhn (30 mg nu <60 kg; 35 mg nu 6069 kg; 40 mg nu 7079 kg; 45 mg nu
8089 kg; v 50 mg nu 90 kg).
Alteplase (tPA): bolus 15 mg, truyn tnh mch 0.75 mg/kg trong 30
pht (ti a 50 mg), sau 0.5 mg/kg (ti a 35 mg) trong 60 pht tip theo;
tng liu khng qu 100 mg.
Streptokinase: 1.5 triu n v truyn tnh mch trong 30 60 pht.
- iu tr tiu si huyt c coi l thnh cng khi:
+ Ht hon ton au ngc
+ ST gim chnh > 50%
- Nn chuyn bnh nhn n c s c kh nng can thip mch vnh
sau khi iu tr tiu si huyt nu iu kin cho php.
3.3. iu tr bin chng
Cn theo di cht bnh nhn pht hin v iu tr kp thi cc bin chng:
- Sc tim
- Suy tim huyt
- Ri lon nhp tim, ri lon dn truyn
- Bin chng c hc
TI LIU THAM KHO

1. ACCF/AHA
(2013): 2013 ACCF/AHA Guideline for the
Management of ST- Elevation Myocardial Infarction: A Report of the
American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines. Circulation. 2013;127:e362-e425.
2. Depta J.P., Kates A.M. (2012): Acute Myocardial Infarction. In: The
Washington Manual of Critical Care (Editors: Kollef M, Isakow W.). Bn dch
ting Vit: Hi sc cp cu Tip cn theo phc , Nxb Khoa hc k thut,
H Ni 2012: 183 205.
3. ESC Clinical Practice Guidelines (2012): Third Universal Definition of
Myocardial, Infarction. European Heart Journal 2012;33:2551-2567.
CU HI LNG GI
Cu 1: ST thay i nh th no chuyn o V2, V3 trong nhi mu c
tim cp c ST chnh ln ngi trn 40 tui:
A. Chnh ln trn 0,10 mV
B. Chnh ln trn 0,15 mV
C. Chnh ln trn 0,20 mV
D. Chnh ln trn 0,25 mV
Cu 2: Phn Killip IV bnh nhn NMCT khi c:
A. Sc tim
B. Ph phi cp
C. Suy tim xung huyt vi ran m 2 y phi
D. Khng c suy tim
Cu 3: Ch nh iu tr ti ti mu cho bnh nhn NMCT cp bng

thuc tiu si huyt khi no
A. Bnh nhn vo vin trong vng 30 pht u sau khi au ngc, c
kh nng chuyn n trung tm can thip tim mch v thc hin c can
thip trong vng 120 pht k t khi au ngc
B. Bnh nhn vo vin trong vng 30 pht u sau khi au ngc v
khng c kh nng chuyn n trung tm can thip tim mch thc hin
c can thip trong vng 120 pht k t khi au ngc
C. Bnh nhn vo vin 3 gi sau khi au ngc.
D. Bnh nhn c tin s xut huyt no cch y 9 thng.
Cu 4: Bnh nhn NMCT cp di 75 tui c dng liu u Clopidogrel
nh th no:
A. 300 mg
B. 225 mg
C. 150 mg
D. 75 mg
Cu 5: Heparin khng phn on tim tnh mch liu bolus u tin cho
bnh nhn NMCTc th dung ti a l bao nhiu n v
A. 2000 n v
B. 3000 n v
C. 4000 n v
D. 5000 n v
53
Bi 8
CP CU CHN THNG S NO
MC TIU
1. Nu c cc du hiu lm sng gi chn thng s no trn bnh

nhn chn thng
2. Nu c mc tiu v nguyn tc x tr chn thng s no ti khoa
cp cu
3. M t phc x tr cp cu chn thng s no ti khoa cp cu
NI DUNG
I. I CNG
Chn thng s no l mt trong nhng chn thng hay gp hng u
trn th gii cng nh ti Vit Nam. Ti Hoa K s ca chn thng s no
nhp vin xp x 235000 lt mt nm. Theo trung tm kim sot bnh tt
Hoa K, s t vong do chn thng s no chim t l 30,5% trong tng s t
vong chung do tai nn thng tch.
54
Ti Vit Nam cng vi s gia tng ca cc tai nn thng tch, t l

chn thng s no cng khng ngng gia tng. Theo thng k t bnh vin
Vit c, ch trong 2 nm 2009 v 2010 c 36.000 trng hp lin quan
n tai nn giao thng nhp vin, trong c 12.000 trng hp chn thng
s no, chim 37%. Ring nm 2011 c 18.000 trng hp tai nn giao
thng nhp vin th c ti 14.000 trng hp chn thng s no, chim t l
gn 80%.
cp cu c hiu qu cc trng hp chn thng ni chung v chn
thng s no ni ring i hi s phi hp cht ch gia cc mt xch trong
dy truyn cp cu, t cp cu trc bnh vin, n khoa cp cu, t cc nh
ngoi khoa chn thng, phu thut thn kinh n cc bc s chuyn khoa hi
sc tch cc.
II. CHN ON
2.1. Triu chng lm sng
- Yu t chn thng (bnh s):
+ y l yu t quan trng cn khai thc ngay khi bnh nhn mi vo
cp cu (s b) v sau khi tin hnh h tr ABC cho bnh nhn (chi tit)
+ Cc yu t cn hi khi khai thc bnh s:
+ C ch chn thng: ng, tai nn giao thng, tai nn sinh hot
+Hon cnh xy ra chn thng
+Thi gian t khi chn thng n lc vo vin
+ thc sau khi xy ra chn thng
+ Tt c bnh nhn chn thng s no cn phi c coi nh c chn
thng ct sng cho n khi c bng chng loi tr
- thc: Thay i thc l du hiu quan trng khi khm bnh nhn
CTSN
BNG IM GLASGOW
4 tui
ngi ln
1 4 tui
< 1 tui
T nhin
T nhin
T nhin
M mt khi
gi
M mt khi
gi
M
mt
khi gi
M mt khi
b
kch
M mt khi
b
kch
M
mt
khi b kch
n
g
55
I
N
I
,
M
T
H
A
N
H
thch au
thch au
thch au
Khng p
ng
Khng p
ng
Khng p
ng
Tnh, nh
hng
(khng
gian, thi
gian)
Gi hi tr
li
ng,
tng tc
Bi b
Gi hi tr
li nhng
ln
ln
(
khng
gian, thi
gian, ngi)
Ni c
nhng ln
ln, c th
d nn c
Quy
khc, kch
thch
Ni cc t
ri
rc,
khng hiu
c
La
ht,
quy khc,
khng d
nn c
Khc khi
b
kch
thch au
, rn r
khng r t
Ch pht ra
m thanh
khng
r
ngha, kch
thch
Rn r khi
b
kch
thch au
Khng p
ng k c
khi b kch
thch
Khng p
ng k c
khi b kch
thch
Khng p
ng k c
khi b kch
thch
Lm
lnh
theo
C ng t
nhin, lm
theo lnh
C ng t
nhin nh
b
tay
hoc khua
tay,
a
tay ra nm
vt.
Khu
tr
c v tr
au ( cu
gt ng)
Khu
tr
c v tr
au ( cu
gt ng)
S
vo
ngi: tr
giy da
Khng khu
tr c v
tr
au
nhng ca
Khng khu
tr c v
tr
au
nhng ca
Kch thch
au:
tr
giy da
N
G
56
quy khi b
kch thch
au
quy khi b
kch thch
au
Co
cng
mt v
Co
cng
mt v
Co cng
mt v
Dui cng
mt no
Dui cng
mt no
Dui cng
mt no
Nm
im,
khng c
ng k c
khi b kch
thch
Nm
im,
khng c
ng k c
khi b kch
thch
Nm im,
khng c
ng k c
khi b kch
thch
Bng 1: Bng im Glasgow cho ngi ln v tr em

Phn
im Glasgow
Nh
GCS: 14 15 im
Trung
bnh
GCS: 9 13 im
Nng
GCS: 3 8 im.
Bng 2: phn loi mc nng ca chn thng s no theo im Glasgow

- Tn thng da u
+ Vt rch, lc da hp s
+ Mu t di da u
- Tn thng xng s:
+ Vt thng s no h: c th thy cht no
+ Vt thng ln s
+ V xng s
+ Vt xuyn thu hp s: n bn, vt sc nhn
- Du hiu v nn s:
+ Chy mu, dch no qu qua tai
+ Chy mu mi, dch no ty qua mi
+ Bm tm hai mt: Du hiu eo knh dm
+ Bm tm vng xng chm ( du hiu Battle)
- Khm ng t:
+ ng t khng u hai bn: mu t ni s
+ ng t hai bn dn, phn x nh sng m tnh: ngh n thot v no
57
+ Du hiu thn kinh khu tr:

+ Lit na ngi
+ Lit cc dy thn kinh s
+ Co git
- Cc du hiu lm sng khc:
+ Co cng mt v
+ Dui cng mt no
Cn lu trc mt trng hp chn thng s no, c th c cc chn
thng khc km theo ( v d v tng c, chn thng ngc kn) v vy
cn phi tin hnh khm ton din mt cch c h thng trnh b st tn
thng
2.2. Cn lm sng
Chp XQ s thng quy: Chp XQ s thng quy c th xc nh tn
thng v xng s v cc d vt xuyn thu vo hp s tuy nhin t c gi tr
xc nh cc tn thng ni s
Chp ct lp vi tnh s no:
- CT s no nn c tin hnh trong vng 1 gi nu:
+ Glasgow < 13 im ti khoa cp cu
+ Glasgow < 15 im 2 gi sau chn thng
+ Nghi ng vt thng s no h hoc vt thng ln s
+ Du hiu v nn s
+ Nn nhiu
+ Co git sau chn thng
+ C du hiu thn kinh khu tr
- CT s no nn c tin hnh trong vng 8 gi nu:
+ Bnh nhn mt thc hoc khng nh cc s vic trc khi chn
thng 30 pht tr v trc
V
+ Tui > 65
+ Hoc c ri lon ng mu ( c th do dng chng ng)
+ Hoc chn thng do tc ng mnh
- i vi bnh nhn < 16 tui cn chp CT ngay nu:
+ Mt thc hoc ln ln > 5 pht
+ Ng g bt thng
+ Nn qu 3 ln
58
+ Glasgow < 14 im
+ Nghi ng vt thng s no h hoc vt thng ln s
+ Du hiu v nn s
+ C du hiu thn kinh khu tr
+ chn thng do tc ng mnh
- Cc xt nghim khc cn lm:
+ Chp XQ ngc
+ Chp ct sng, c bit ct sng c
+ Siu m bng, mng phi
+ in tim, kh mu, sinh ha, t bo
III. X TR CP CU CHN THNG S NO
3.1. X tr cp cu ti khoa cp cu
- Mc tiu x tr cp cu chn thng s no ti khoa cp cu
+ Bo v ng th
+ Duy tr p lc ni s bnh thng
+ Gim p ni s nu tng
+ Duy tr bo ha oxy > 90%
+ HA tm thu > 90 mmHg
+ p lc ni s 20 mmHg
+ iu chnh ng huyt, trnh tng hoc gim
+ An thn
+ X tr vt thng
+ Chng co git
- nh gi ban u: thc, ng th, h hp, tun hon
- Lun duy tr cc phng tin c nh ct sng c cho n khi loi tr
tn thng ct sng c. Khuyn co s dng Guideline tho b cc phng
tin c nh ct sng c.
- Bo v ng th: t ni kh qun nu cn. Cn nhc t ni kh
qun sm i vi cc bnh nhn sau:
+ Glasgow 8 hoc suy gim thc nhanh
+ Nn nhiu
+ PaO2 < 80 mmHg
+ PaCO2 > 45 mmHg
+ Chn thng hm mt
59
+ Nguy c chy mu vo ng th
+ Co git
- H tr h hp:
+ Bp bng ambu hoc thng kh nhn to bng my th nu cn
+ Bo m cung cp y oxy cho bnh nhn m bo PaO2>80
mmHg
+ Kch thch dy da c th lm tng p lc ni s v lm trm trng
thm tn thng no v vy cn nhc s dng an thn cho cc bnh nhn kch
thch nhiu.
- H tr tun hon:
+ Bng p cm mu
+ Hi sc dch bng cc dung dch tinh th v dung dch keo duy tr
huyt p trung bnh > 65 mmHg. Truyn mu v cc ch phm mu nu cn
+ S dng cc thuc vn mch nng huyt p sau khi b dch
+ C th t ng truyn tnh mch trung tm theo di p lc tnh
mch trung tm (CVP) v b dch
- Sau khi x tr ABC cn bc l bnh nhn, khm ton thn, trnh b
st tn thng.
- Cn lu loi tr cc nguyn nhn gy hn m khc nh h ng
huyt, ng c.
- X tr vt thng: bng p, cm mu
- Khi c du hiu tng p lc ni s, c th s dng Manitol 1,5 2 g
truyn tnh mch trong 30-60 pht
+ Cc du hiu gi tng p lc ni s trong chn thng s no
. Dn ng t mt bn
. dn ng t c hai bn, mt phn x nh sng
. im Glasgow gim > 2 im so vi lc khm trc
. co cng hoc dui cng
. xut hin phn x Cushing: tng huyt p, nhp tim chm, ri lon
nhp th
- i vi cc vt thng xuyn thu, tuyt i khng rt cc vt xuyn
thu ra khi hp s ti khoa cp cu.
- Chp X quang, CT Sanner khi tnh trng bnh nhn cho php
- Hi chn bc s chuyn khoa phu thut thn kinh, tin hnh phu
thut khi c ch nh.
60
Phc x tr bnh nhn chn thng s no nh

Glasgow 13-15
Khai thc tin s bnh s

C ch chn thng
Thi gian b chn thng
Mt thc ngay sau chn thng?
Qun cc s kin trc v sau chn thng?
au u: nh, va, trung bnh
Khm tng qut loi tr cc thng tn khc
Khm pht hin cc du hiu thn kinh khu tr
Chp XQ ct sng c v cc b phn khc (nu cn)
o nng cn mu v theo tm c cht nc tiu

nu nghi ng
Tiu chun nhp vin
- Khng chp c CT
- CT s bt thng
- Vt thng xuyn s
- Tin s mt thc ko
di
- thc xu i
- au u mc trung
bnh v nng
- Ng c ru v ma ty
- V xng s
- D dch no ty
- C cc chn thng
khc phi hp
- Kh theo di ti nh
- C du hiu TK khu tr
- Glasgow < 15
Chp CT s no nu:
- Glasgow < 15 im
sau 2 gi k t khi
chn thng
- Nghi ng vt
thng s no h
hoc ln s
- C du hiu v nn
s
- Nn hn 2 ln
- > 65 tui
61
Tiu chun ra vin

-Khng c tiu chun
nhp vin (nh bn)
- Dn bnh nhn taosi
khm nu c vn
- Hn lch khm li
Phc x tr bnh nhn chn thng s no va

Glasgow 9 12
Khm ban u
Nh trong chn thng s no nh
Chp CT s cho tt c cc trng hp CTSN va
Nhp vin, vo khoa phu thut thn kinh
Sau khi nhp vin

Khm thn kinh thng xuyn
Chp li CT s no nu din bin xu i
Chp li CT s no trc khi cho xut vin
Tnh trng bnh nhn

ci thin
Xut vin
Ti khm
Tnh trng bnh

nhn xu i
Chp li CT s no
X tr nh chn
thng s no
nng
62
Phc x tr bnh nhn chn thng s no nng

Glasgow 3 - 8 im
nh gi v x tr
1. Ct sng c, ABCDEs
A: bo v ng th, n c nhc cm, canyl ming hu, mi hu, t NKQ,
mt n thanh qun..
B: h tr h hp: oxy liu php, bp bng, th my xm nhp, khng xm
nhp. Duy tr bo ha oxy > 90%, CO2 35-45 mmHg
C: h tr tun hon: t ng truyn, truyn dch tinh th, dch cao phn t,
duy tr huyt p. Kim sot chy mu, bng p, np, duy tr HA tm thu > 90
mmHg
D: khm thn kinh: Glasgow, ng t, du hin thn kinh khu tr. Gim p
ni s bng manitol 20% nu c du hiu tng ALNS. Chng co git
E: bc l khm ton thn, khng b st tn thng, m
2. nh gi th 2
Hi tin s, bnh s
Khm chn thng nhanh
Du hiu sinh tn
Khm lm sng chi tit
3. Hi chn chuyn khoa phu thut thn kinh
4. Chp CT s no khi tnh trng bnh nhn cho php v cc xt nghip cn thit
khc
5. Chuyn phu thut cng sm cng tt khi c ch nh
63
TI LIU THAM KHO

1. Robert S. Hockberger, Ron M. Walls, James G. Adams. Rosens
emergency medicine: concepts and clinical practice. 2010
2. John Bailitz, Faran Bokhari, Tom Scaletta, Jeffrey Scheider.
Emergent Management of Trauma. 2011
3. Barbara Aehlert. Paramedic Practice Today above and beyond. 2010
4. Will Chapleau , Angel Burba, Peter Pons, David Page. The
Paramedic 2009
5. American College of Surgeons. Advanced Trauma Life Support for
Doctors. 2008
6. Forrest O. Moore et al. Surgical Critical Care and Emergency
Surgery, Clinical Questions and Answers. 2012
CU HI LNG GI
1. Triu chng lm sng no sau y gi tnh trang tng p lc ni s
trn bnh nhn chn thng s no:
A. Suy h hp
B. im Glasgow gim hn 2 im
C. Gy cng
D. Lit na ngi
2. Chn cu tr li ng sai
Tng thng kh dn n dn mch no v tng p lc ni s, v vy i
vi bnh nhn chn thng s no, cn trnh tng thng kh v duy tr PaCO2
35-35mmHg
A. ng
B. Sai
3. Trn bnh nhn chn thng s no Tr s p lc ni s (mmHg) no
sau y c ch nh can thip gim p:
A. 10
B. 20
C. 30
D. 40
64
Bi 9
CP CU CHN THNG CT SNG
MC TIU
1. M t c cc triu chng lm sng, cn lm sng ca chn thng

ct sng
2. Nu c cc nguyn tc x tr chn thng ct sng ti khoa cp
cu
3. Nu c nguyn tc bt ng ct sng c v nguyn tc tho np c
ti khoa cp cu
NI DUNG
I. I CNG
Chn thng ct sng l mt chn thng thng gp v l tnh trng
cp cu e da tnh mng, c th li bin chng, di chng sut i. Hoa
K, t l chn thng ct sng xp x 50000 trng hp mt nm. Vit
Nam cha c con s thng k chnh thc, tuy nhin vi t l tai nn giao
thng rt cao nc ta chc chn t l chn thng ct sng khng phi l
nh.
Theo cc thng k, a s cc bnh nhn b chn thng ct sng u
ang trong tui lao ng, chnh v vy cp cu chn thng ct sng
nhanh chng, ng cch c th gip hn ch t l tn tt, di chng.
Cc nguyn nhn thng gp dn n chn thng ct sng:
- Tai nn giao thng 48%
- Ng cao 21%
- Xung t 15%
- Chn thng trong th thao 14%
Trong
- Chn thng ct sng c 55%
- Ct sng ngc 15%
- Ct sng tht lng: 15%
- Cng ct 15%
C ch chn thng
65
- n ct sng qu mc
- Nga ct sng qu mc
- Do lc tc ng t bn vo ct sng
- Do lc p xung theo chiu dc ct sng
- Do lc ko dn theo chiu dc ct sng
II. CHN ON
2.1. Nguyn tc khm cp cu trng hp nghi ng chn thng
ct sng
- Trong tt c cc trng hp chn thng cn coi nh c chn thng
ct sng c
- Khi khm cn bc l v khm ton b ct sng
- Cc bnh nhn c thay i thc, say ru, a chn thng cn duy
tr cc phng tin c nh ct sng c cho n khi c bng chng chc chn
loi tr chn thng
- au vng ct sng, au tng khi s nn ct sng
- Bin dng ct sng
- Cc du hiu ng dp, bm tm vng ct sng
- Lit:
+ T chi: ct sng c
+ Lit 2 chi di
+ Lit c h hp
+ Ri lon c trn
+ Cng dng
- Mt/gim vn ng, cm gic chi
2.3. nh khu tn thng ty sng
66
V
tr
tn
thng
Vn ng
Cm
gic
C4
C honh/h hp
Trn
hm c
C5
C delta/nhn vai
Di
xng
n
Nh u
C6
C
nh
u/gp
khuu tay/nga c
tay
Ngn ci
Nh u
C7
C tam u/ dui
khuu tay
Ngn
gia
Tam
u
C8
C gp/gp ngn tay
Ngn t
T1
Gian t/ xe ngn
Mt
trong
cnh tay
T4
C gian sn/h hp
Nm v
Mi c
T8
T10
C thng bng
Rn
67
Phn
x
T12
G mu
L1/L2
C i
hng
chu/dui
L3
C t u/dui gi
Vng
gia i
Bnh
ch
L4
C t u/dui gi
Ngn
chn ci
Bnh
ch
L5
C
dui
ngn
chn/gp ngn chn
ci
Ngn
gia bn
chn
S1
C nh u v c dp/
dui bn chn
Ngn
chn t
Gn
Achilles
S2/S3/S4
C tht hu mn/rut
v bng quang
y chu
Co tht
hu
mn
Vng
trn i
2.4. nh gi chc nng vn ng

im
Biu hin lm sng
Lit hon ton
Nhn thy c mp my hoc s thy c vn ng
Khng th vn ng khng trng lc
C th vn ng khng trng lc
Gim nh, pht hin khi bnh nhn co c khng tr lc
Bnh thng
68
2.5 nh khu tn thng ct sng da vo Chc nng h hp

Mc gim dung tch
sng (VC)
V tr tn thng ct sng tng

ng
95%
Ct sng c, on cao: C1-C4
75%
Ct sng c, on thp: C5-C7
50%
Ct sng ngc on cao: N1-N9
0%
Thp di t ngc 10
2.6. Cc hi chng tn thng ty sng
Hi chng trung tm:
- Tn thng trung tm ty sng
- Tn thng cm gic vn ng chi trn nhiu hn chi di
- Tn thng vn ng gc chi nhiu hn ngn chi
- Cm gic bng rt hai chi trn
Hi chng Brown-Sequard
- Tn thng mt na ty sng
- Hay gp trong vt thng xuyn thu ty sng hoc u chn p ty
sng
- Mt vn ng, nhn cm rung, cm gic bn th cng bn vi tn
thng ty
- Mt cm gic au v cm nhn nhit i bn vi tn thng ty
Hi chng sng trc
- Tn thng sng trc ty sng
- Lit vn ng ( nhiu mc ) v mt cm gic au vng di tn
thng
- Cn cm nhn c rung ng v cm gic bn th
Hi chng sng sau
- Him gp
- Tn thng sng sau ty sng
- Mt cm gic vng di tn thng
- Chc nng vn ng t b nh hng
Hi chng chp ty
- Tn thng ty sng vng cng ct
- B i do mt phn x bng quang
69
- Lit vn ng v mt cm gic hai chi di ( nhiu mc )

Hi chng ui nga
- Do tn thng cc r thn kinh xut pht t ct sng tht lng cng
- B i do mt phn x bng quang
- Lit vn ng v mt cm gic hai chi di ( nhiu mc )
- Mt phn x hai chi di
Hi chng sc ty (spinal shock)
- Thng xut hin sau khi tn thng ty sng 24h
- Nguyn nhn do tn thng ty sng hon ton
- Mt ton b phn x, cm gic vn ng di tn thng
- i tin khng t ch, b i, cng dng
- Khng lin quan n gim th tch
- C th phc hi hoc khng phc hi
Hi chng sc Thn kinh (Neurogenic shock)
- Tn thng ty sng t t ngc 6 tr ln
- Tn thng ty sng gy mt trng lc giao cm thnh mch v tt
huyt p
- Nhp tim bnh thng hoc chm
- Biu hin dn mch ngoi bin
2.7. Cn lm sng
- Ngoi cc xt nghim thng quy, cc thm d chn on hnh nh c
gi tr ln trong chn on v x tr chn thng ct sng
- Cc thm d chn on hnh nh cn lm l:
+ Chp XQ thng 3 t th: thng, nghing, h mm
+ Chp ct lp vi tnh ct sng
+ Chp cng hng t ct sng
+ Siu m pht hin cc tn thng khc: Trn dch trn mu mng
phi, chn thng tng, trn mu bng
III. X TR CP CU CHN THNG CT SNG
3.1. X tr cp cu ti khoa cp cu
a) Bt ng ct sng c
- Bt c trng hp chn thng no cng nn coi nh c chn thng
ct sng c
70
- Khng nn v cc tn thng bt mt khc nh chy mu, bin

dng chi m qun ct sng, c bit l ct sng c
- Bt ng ct sng c bng np c hoc cc phng tin c nh tng
ng
b) Khm ban u (th 1) ch trng vo ng th, h hp, tun hon
(ABCDE) pht hin v x tr ngay cc tnh trng e da tnh mng bnh
nhn
X tr ng th:
- Bo m ct sng c bt ng trong khi x tr cp cu
- t ni kh qun (ming/mi), mt n thanh qun
- M kh qun cp cu qua mng nhn gip nu cn
H tr h hp:
- Pht hin trn kh mng phi v chc ht dn lu kh cp, nu c
- Bp bng qua ni kh qun
- Thng kh nhn to
- Oxy liu php
H tr tun hon:
- t ng truyn tnh mch. Trong trng hp bnh nhn nng c
th t hai ng truyn ln (14 16 G) hoc t catheter TM trung tm hoc
ng truyn trc xng chy
- Truyn dch tinh th, dch cao phn t b khi lng tun hon
trong trng hp sc. Truyn mu v cc ch phm mu trong trng hp
mt mu nng
- Cm mu: bng p, bt ng chi gy, garo
nh gi tnh trng tinh thn kinh
Bc l ton b bnh nhn, trnh b st tn thng
c) Khm chi tit (th 2)
- Khm chn thng t u n chn, khng b st cc tn thng
khc
- Tin hnh cc xt nghim, chiu chp x tr tip
- Hi chn vi chuyn khoa ngoi chn thng, chuyn khoa ngoi ct
sng.
3.2. Thuc
- Hin nay cha c thuc iu tr gip ci thin tin lng ca tn
thng ty sng
71
- Mc ch s dng cc thuc ch yu h tr d phng tn thng

ty sng th pht do gim ti mu, ph ty
- Vic s dng corticoid trong chn thng ct sng hin vn cn cha
thng nht v c nhiu kin tranh ci
- Mt s tc gi ng h vic s dng corticoid rng corticoid c th
gip lm gim tnh trng ph n ty sng nu dng liu cao trong 8 gi u.
Liu lng Methylprednisolone: Bolus 30mg/kg/15ph, duy tr 5,4 mg/kg/h x
23 h (The National Association of Spinal Cord Injury Studies)
3.3. Cc phng tin c nh ct sng
a) Np c
- Lun nh bt ng ct sng c cho cc trng hp chn thng, c
bit nhng chn thng do lc tc ng ln, bnh nhn thay i thc, tr
em, ngi gi, c triu chng nghi ng tn thng ct sng
- Trc khi eo np c: lun bt ng ct sng c bng cch dng hay
tay gi vng u v c bnh nhn
- Phi chn c np c ph hp. Np c c ln qu khng bo m bt
ng ct sng, np c c nh qu c th lm tn thng thm ct sng
- Np c mm khng c tc dng c nh ct sng
- Khi tho np c, cn tun th cht ch cc protocol
b) Cng cng
- KHNG dng cng mm vn chuyn bnh nhn chn thng.
- S dng k thut log-roll t bnh nhn ln cng cng.
- Khi t bnh nhn trn cng cng cn phi c cc phng tin (dy,
ai) c nh (buc) bnh nhn chc chn. Lu khi c nh phi c nh thn
mnh ca bnh nhn trc sau mi n c nh u.
- Khi n bnh vin, chuyn bnh nhn ra khi cng cng cng sm
cng tt. Bnh nhn nm cng cng lu hn 2 gi c nguy c cao b lot do t
c) Phng tin c nh u
Ch dng np c khng hiu qu bt ng ct sng c
Cn kt hp np c, c nh u v cng cng
- Khi khng c sn phng tin c nh u, c th s dng hai cun
khn tm ( hoc ga) hai bn u bnh nhn sau c nh bng bng cun
hoc bng dnh
3.5. Tho b cc phng tin c nh ct sng c ti khoa cp cu
a) Cc bnh nhn khng c triu chng lm sng
72
Phi c cc tiu chun sau mi c tho np c (NEXUS

Guidelines)
- Tnh p ng tt
- Khng au, nhy cm/cm ng ct sng c
- Khng c du hiu TK khu tr
- Khng say ru
- Khng c cc chn thng gy ch khc (v d chy mu ngoi, gy
chi)
b) Cc bnh nhn c triu chng lm sng:
- Lun duy tr cc phng tin bt ng ct sng c cho n khi c
bng chng loi tr tn thng
- Cn tin hnh cc thm d chn on hnh nh xc nh tn thng
+ XQ 3 t th: trc-sau, bn, h mm
+ CT
+ MRI
- Hi chn chuyn khoa ngoi chn thng, phu thut thn kinh, ct
sng
c) Cc bnh nhn khng nh gi c
- Cc bnh nhn ny bao gm
+ Bnh nhn hn m
+ Bnh nhn t NKQ, an thn
+ Bnh nhn say ru
+ C vt thng chn thng gy ch
Lun duy tr cc phng tin bt ng CS c cho n khi c bng
chng loi tr ng thi Theo di lm sng, Tin hnh cc thm d chn on
hnh nh v Hi chn chuyn khoa tin hnh cc thm d chn on hnh nh
73
Tiu chun tho phng tin bt ng ct sng c da vo lm sng

(ch p dng cho bnh nhn tnh hon ton, Glassgow >14)
Vikas V. Patel, Evalina Burger 2010
Hi tin s t m
Khm lm sng ton din
Bnh nhn tnh, nh hng

Khng au c
Khng tng au khi khm c
Khng c du hiu TK khu tr
Say ru
Hoc
C chn thng
gy ch khc
khng
Khng tiu chun tho np c

Tip tc duy tr np c
Lm test quay
c 45 sang
tri v sang phi
Tht bi
Chn on hnh nh
Thnh cng
74
Ct sng c an ton
Tho np c
TI LIU THAM KHO

1. R. Roberts, Jerris R. Hedges. Clinical procedures in emergency
medicine 2010
4. Colin R Anderson, Ken WS Ashwell, Han Collewijn et al. The
Spinal Cord: A Christopher and Dana Reeve Foundation Text and Atlas. 2009
Paramedic 2009
Doctors. 2008
CU HI LNG GI
1. Bnh nhn nam 35 tui vo cp cu sau tai nn giao thng, bnh
nhn tnh, gy kn xng cng tay tri v xng cng chn tri. T b chn tay
Vic u tin cn lm l:
A. o du hiu sinh tn mch, huyt p, nhit
B. khai thng ng th
C. t ng truyn TM
D. c nh ct sng c
E. np, bt ng cng tay v cng chn bn tri
F. khng c cu no ng
2. Chn cu tr li ng sai
Trong trng hp chn thng ct sng c, ch cn cho bnh nhn eo
np c ng cch l c th bo m bt ng ct sng c
A. ng
B. Sai
3. Mt bnh nhn c a vo cp cu do tai nn giao thng, gi
bnh nhn m mt, kch thch au gt ng, ni r ting khi gi hi nhng
75
ln xn. Bnh nhn c nhn vin cp cu 115 np c, ang nm cng

cng, khng tm mi, mch r cha thy du hiu thn kinh khu tr. Can
thip no sau y khng c tin hnh
A. o du hiu sinh tn
B. oxy liu php
C. tho b np c
D. khm ton thn
E. a bnh nhn i chp CT s no
76
Bi 10
CP CU CHN THNG NGC
MC TIU
1. Nu c nguyn tc x tr cp cu chn thng ngc ti khoa cp

cu
2. M t triu chng ca su loi chn thng ngc e da tnh mng
bnh nhn ngay lp tc
3. Nu c cc bin php x tr cc chn thng ngc ti khoa cp
cu
NI DUNG
I. I CNG
Nhiu bnh nhn b chn thng ngc nng cht trc khi h n bnh
vin, Tuy nhin, mt t l ln cn sng v cn khm nh gi x tr cp cu
ngay lp tc. Vic cp cu ng cch v khn trng c tnh cht quyt nh.
Chn thng ngc c th nhiu mc khc nhau, t tn thng nh
nh chn ng ngc n cc tn thng nng nh vt thng thu tim hoc
ng dp cc mch mu ln trong lng ngc.
Theo thng k chn thng ngc thn gp do tai nn giao thng,
trong di 10% cc chn thng ngc kn v xp x 30% vt thng thu
ngc hoc chn thng ngc h cn phi can thip phu thut ngay lp tc.
Cc chn thng ngc e da tnh mng ngay lp tc bao gm :
- Tc nghn ng th
- Trn kh mng phi p lc
- Trn mu mng phi ln
- Vt thng ngc h
- Mng sn di ng
- p tim cp
II. CHN ON V X TR CHN THNG NGC
2.1. Nguyn tc x tr cp cu chn thng ngc:
a. X tr cp cu trc bnh vin
- Bt ng ct sng c
77
- nh gi v x tr ABC : ng th h hp tun hon

- Chc ht dn lu kh mng phi nu nghi ng
- Oxy liu php, chng sc
- Nu c vt xuyn thu vo ngc khng c rt ra, c nh chc chn
vt xuyn thu v vn chuyn n bnh vin cng bnh nhn
- Vn chuyn nhanh n bnh vin
- nh gi li lin tc trn ng vn chuyn
b. X tr cp cu ti khoa cp cu
Thm khm th u (primary survey)
nh gi v x tr theo trnh t cc bc ABCD. nh gi nhanh (2
pht), tin hnh x tr ngay sau khi pht hin tn thng v nhc li nh gi
bt c lc no khi bnh nhn khng n nh.
Lun lu bo m bt ng ct sng c cho n khi loi tr tn
thng. Trong trng hp np c gy kh khn cho th thut t ni kh qun,
c th tho phn trc ca np c, duy tr bt ng ct sng c bng tay, lp
li np c khi tin hnh xong th thut
Airway (A): ng th
- Xc nh c hay khng tc nghn ng th.
- Lu tn thng ng h hp trn.
- Nu c phi x tr ngay m bo ng th lun thng thong.
- Kim sot ng th nng cao : t Ni kh qun, mt n thanh qun,
ng kt hp.
Breathing (B): H hp
Pht hin v x tr ngay ngay cc du hiu v nguyn nhn gy suy h
hp cp do chn thng ngc:
- Tc nghn ng th
- Vt thng ngc h
- Trn mu mng phi ln
- Mng sn di ng
- Chn p tim cp
Oxy liu php : qua knh mi hoc cc loi mt n
H tr h hp : thng kh nhn to xm nhp v khng xm nhp
Circulation (C): Tun hon
- Kim sot chy mu: bng p cm mu, bt ng chi gy, garo
78
- X tr sc:
+ Hi sc dch
+ u thp chn cao
+Phu thut cm mu i vi cc chy mu trong
2. Thm khm th hai ( secondary survey)
Tin hnh khi cc du hiu e da tnh mng c chn on, x tr
hoc loi tr. Cn nh gi li ton b, chi tit v lm thm cc thm d khc
pht hin tn thng nh chp XQ, siu m, CT, xt nghim.
3. Tip cn a chuyn khoa:
t c cht lng x tr cp cu cao nht cho cc bnh nhn chn
thng ngc ni ring v cc bnh nhn chn thng ni chung, cn c c
ch phi hp nhp nhng gia cc chuyn khoa: Cp cu Hi sc Ngoi
khoa Chn on hnh nh
2.2. Tc nghn ng th
( xem thm bi kim sot ng th)
X tr ng th :
- n c nhc cm hoc n hm
- Ly b d vt: th thut Hemlich, ht ming, hu hng, gp d vt
bng panh magi (nu c th)
- t ng th ph ming hu ( canyl mayo/Guedel) hoc mi hu
( nu c)
- Kim sot ng th nng cao : t Ni kh qun, mt n thanh qun,
ng kt hp.
- Cc trng hp ng th kh :
+ M kh qun mt th cp cu
+ M mng nhn gip cp cu
2.3. Trn kh mng phi p lc
2.3.1. Chn on:
- Suy h hp cp tnh: th nhanh, tm mi v u chi, gim oxy ha
mu
- Ri lon huyt ng: nhp tim nhanh, tt huyt p, tnh mch c ni
- Triu chng trn kh mng phi
+ Lng ngc cng phng mt bn,
+ R ro ph nang gim hoc mt,
+ G vang trng,
+ C th thy trn kh di da
79
+ Kh qun b y lch sang bn i din

2.3.2. X tr ti khoa cp cu
nh gi v x tr ABC
- Chc gim p mng phi:
+ S dng kim c ln ( 10-16 G) ni vi xylanh chc vo khoang
mng phi,
+ im chc khoang lin sn 2 ng gia n
+ hng kim i vung gc vi mt da
+ chn khng trong tay cho n khi thy kh trn vo xylanh
+ Ni kim vi h thng ht p lc thp hoc h
- M mng phi ti thiu
- Ht lin tc p lc thp
- Pht hin v x tr cc thng tn khc i km
2.4. Vt thng ngc h
2.4.1. Chn on
- Du hiu ph ph qua vt thng h ngc, c th thy mu v
dch si qua vt thng khi bnh nhn th
- Gim gin n ca thnh ngc trong th ht vo.
- R ro ph nang gim hoc mt.
- nh gi v x tr ABC nng cao
- Bt vt thng ngc h bng cch to mt van mt chiu trn vt
thng lm cho kh ch i t trong khoang mng phi i ra m khng i
ngc tr li c. Th thut ny gip ngn nga vt thng ngc h tin
trin thnh trn kh mng phi p lc. S dng mt ming nilon mng, sch
(V khun cng tt), hnh vung. Dng bng dnh dn kn 3 cnh ca ming
nilon. Cnh cn li ch dn kn 2/3. Hin nay c cc sn phm thng mi
c c ch tc dng tng t v d nt bt ngc Asherman
- C th dn lu mng phi hoc m mng phi cp cu nu c trn
dch, trn kh mng phi nhiu
- Pht hin cc thng tn khc i km
- Hi chn chuyn khoa ngoi
2.5. Trn mu mng phi nhiu
2.5.1. Chn on
- Kh th, gim bo ha oxy mu
- Di ng lng ngc gim
80
- Bn tn thng: r ro ph nang gim hoc mt, g c, rung thanh

tng
- C th c cc du hiu chn thng ngc: bm tm, gy xng sn,
vt thng ngc h
- Tt huyt p do sc mt mu
- Du hiu thiu mu: da xanh nim mc nht, mch nhanh, khng thy
mt mu cc c quan khc
- nh gi v x tr ABC
- Truyn dch tinh th hoc truyn mu nu cn
- Dn lu bng kim hoc m mng phi ti thiu nu trn mu mc
nhiu
- Lu chng sc, b dch, mu trc khi tin hnh th thut dn lu
- Tin hnh chp CT, XQ khi tnh trng bnh nhn cho php
- Hi chn chuyn khoa ngoi
2.6. Mng sn di ng
2.6.1. Chn on:
- Mt on ngc mt tnh lin tc ca xng (hay c 3 xng sn k
nhau b gy 2 im trn 1 xng sn).
- Di ng bt thng ca mt on ngc khi bnh nhn t th, vng
tn thng di ng ngc chiu vi lng ngc khi h hp
- Th nng do bnh nhn au khng dm th mnh
- S nn vng xng sn gy c ting lo xo.
- Du hiu gy nhiu xng sn trn XQ.
- X tr v bo m ABC, oxy liu php
- Gim au gip bnh nhn ci thin ri lon h hp gy ra do mng
sn di ng
- Nhiu bng chng cho thy th CPAP khng xm nhp gip bnh
nhn b mng sn di ng ci thin tt tnh trng oxy ha mu v trnh c
t ni kh qun.
- X tr mng sn di ng bng cch t ti ct hoc nm nghing
sang bn tn thng khng cn c p dng trong c cp cu trc bnh
vin v khoa cp cu do lm gim s dn n phi v lm xp phi bn b
tn thng.
- Lu trn kh mng phi c th xy ra bn phi b tn thng.
81
- C nh mng sn di ng bng phu thut sm cn ang tip tc

c tranh lun. Nhiu tc gi ng h phu thut khi:
+ Bnh nhn kh cai my do mng sn di ng
+ au ko di
+ Lng ngc mt vng nng
+ Chc nng h hp c xu hng xu i
2.7. p tim cp
2.7.1. Chn on
- Kh th d di, suy h hp cp
- Huyt p tt
- C th c vt thng h hoc vt thng xuyn thu vng ngc, bng
- Tnh mch c ni ( c th khng c du hiu ny nu bnh nhn c
tnh trng sc, nht l sc mt mu)
- Ting tim nghe m, nhp tim nhanh
- in tim: gim in th ngoi bin
- Siu m: dch mng ngoi tim
- nh gi v x tr ABC nng cao
- Kim sot ng th: t ni kh qun nu cn
- H tr h hp: oxy liu php, th my
- H tr tun hon: t hai ng truyn c ln, truyn dch tinh th,
cao phn t, mu v cc ch phm mu nu cn
- t ng truyn tnh mch trung tm, hi sc dch v theo di p lc
tnh mch trung tm
- Chc ht dn lu dch, mu mng ngoi tim. Cn lu trn dch
mng tim p tim cp trong chn thng thng do vt thng ngc h hoc
xuyn thu gy chy mu vo mng ngoi tim, dch mng ngoi tim nhiu
mu cc, mu ti thng gy tc dn lu v vy mt s tc gi ng h vic
dn lu mng ngoi tim bng th thut m mng tim ti thiu hoc m ngc
ti phng m
- Pht hin v x tr trn kh mng phi i km
- Khng rt vt xuyn thu ra khi lng ngc ti khoa cp cu, c nh
chc chn, hi chn chuyn khoa ngoi chn thng chuyn phng m.
3. Nhng tn thng khc trong chn thng ngc:
3.1. ng dp tim
Chn on:
82
- C ch chn thng: va p trc tip vo vng tim, v xng c.

- Thng d b b st do ln trong bnh cnh chn thng
- au ngc vng trc tim, d nhm vi au do gy xng c hoc
xng sn.
- Men tim tng: CPK, CPK-MB, SGOT, SGPT, Troponin I, T
- ECG: lon nhp tim, ST chnh ln v sng T m, tuy nhin t khi c
hnh nh in hnh nh trong nhi mu c tim.
- Siu m: gim vn ng thnh c tim, trn dch mng tim.
X tr:
- ABCDE
- t Catheter TMTT, s dng thuc vn mch (v d Dobutamin) x
tr sc tim
- Bnh nhn cn c iu tr v theo di nh mt trng hp nhi
mu c tim, tuy nhin cc thuc chng ng mu thng chng ch nh
trong bnh cnh chn thng cp
- Theo di lm sng, in tim, men tim lin tc
- Hi chn chuyn khoa ngoi lng ngc.
3.2. Dp v ng mch ch do chn thng
Chn on:
- T l t vong cao, ln ti 90% sau chn thng
- C ch chn thng: va p trc tip hoc tn thng do gia tc gim
t.
- au ngc hoc au lng vng ct sng ngc
- Triu chng sc, khng kim sot c
- Mch mt na thn mnh gim hoc mt
- Huyt p hai tay khc nhau
- XQ ngc: c th c trung tht rng, gy xng sn s 1 hoc 2, ph
qun gc bn phi b y ln cao, ph qun gc bn tri xung thp, trc kh
qun lch sang phi, trn mu mng phi tri.
- CT ngc: nhy 92-100%, c hiu 82-100%.
X tr:
- Cn phu thut cp cu sm nht.
- Nu phi chuyn bnh nhn: bnh nhn phi c an thn th my,
gi huyt p ti a <100 mmHg, phng v bng cc thuc propanolol hoc
Nitroprusside.
3.3. V c honh
83
Chn on:
- C th c suy h hp: ph thuc vo din c honh tn thng v s
thot v ca tng bng ln phi.
- Nghe phi c th thy ting nhu ng ca d dy rut, mt r ro ph
nang.
- XQ: bng hi d dy ln khoang mng phi; ng thng d dy nm trn
ngc.
- Ni soi lng ngc chn on chnh xc 98% v c honh.
X tr:
- ABC
- t sonde d dy dn lu thc n v dch v
- Hi chn chuyn khoa ngoi, m sm
- Phu thut m bng a tng thot v xung bng v khu phc hi
c honh.
- C th m ngc hoc ni soi lng ngc x tr tn thng.
3.4. Tn thng thanh-kh-ph qun
Chn on:
- Chn thng vo vng c, ngc.
- Kh th, c th d di.
- Ho ra mu.
- Trn kh di da, trn kh mng phi p lc hoc trn kh mng phi
mc nhiu (kh ra lin tc theo dn lu), dn lu ko di khng ht kh
- CT lng ngc c th chn on cc tn thng kh ph qun v trung
tht
- Ni soi ng th cho php chn on chnh xc.
X tr:
- ABC
- Khuyn co t ni kh qun qua ni soi ti ging nu c iu kin
- Khi bnh nhn c chn thng thanh kh qun: u tin m kh qun
cp cu di ch tn thng. Nu phi t ni kh qun cn c tin hnh
thn trng bi nhn vin y t c kinh nghim v nguy c cao gy tn thng
thm, thm ch t ri thanh kh qun
- Hi chn ngoi khoa m cp cu x tr tn thng cng sm cng tt.
3.5. Chn thng thc qun
Chn on:
84
- C ch chn thng: lc tc ng t ngt vo vng bng trn hoc

vt thng m xuyn vo vng thc qun.
- Chp thc qun c thuc cn quang hoc ni soi thc qun.
X tr:
- Phu thut cp cu thc qun, dn lu trung tht hoc mng phi.
- Chng ch nh t sonde d dy nu vt thng xuyn thu thc
qun
- M thng d dy.
- Kt hp khng sinh tch cc
3.6. ng dp phi
Chn on:
- C tn thng: bm dp thnh ngc, gy xng sn, hoc mng sn
di ng.
- XQ ngc: cc m tng t trng khng ng nht bn phi tn
thng.
- CT scanner: cho php phn bit vi tn thng do tro ngc, xp phi.
X tr:
- Kim sot au tt.
- Th oxy v l liu php ngc.
- t ni kh qun v th my nu c suy h hp nng.
TI LIU THAM KHO
Paramedic 2009
Doctors. 2008
6. Forrest O. Moore et al. Surgical Critical Care and Emergency
Surgery, Clinical Questions and Answers. 2012
7. Paul E. Pepe, Marc Eckstein. Reappraising the prehospital care of
the patient with major trauma. Emergency Medicine Clinics of North
America, Volume 16, Issue 1, Pages 1-15
85
8. Nguyn Hu T. Chn thng ngc. Hng dn cp cu chn

thng. B Y t 2008
CU HI LNG GI
1. Trong chn thng ngc, loi chn thng no sau y l chn
thng e da tnh mng ngay lp tc
A. ng dp phi
B. Mng sn di ng
C. ng dp tim n thun
D. Trn kh mng phi p lc
E. B,D
F. A,C
2. Trong p tim cp do trn mu mng ngoi tim, bin php x tr no
sau y cn phi c thc hin trc :
A. Chc ht dn lu mng ngoi tim
B. M lng ngc cp cu
C. nh gi v x tr ng th h hp tun hon
D. t ng truyn TM trung tm s dng thuc vn mch
3. Trong chn thng ngc, Bin php x tr no sau y khng c
tin hnh ti khoa cp cu :
A. M mng phi ti thiu
B. M ngc cp cu
C. Rt vt xuyn thu khi lng ngc
D. Cc th thut trn u c tin hnh ti khoa cp cu
86
Bi 11
CP CU CHN THNG BNG
MC TIU
1. Nu c cc triu chng lm sng gi chn thng bng
2. M t cc bin php thm d cp cu lm sng, cn lm sng xc
nh chn thng bng v nguyn tc thc hin
3. Nu c cc nguyn tc x tr cp cu chn thng bng kn, h
NI DUNG
I. I CNG
Cc c quan trong bng khng c h thng khung xng che , nn
rt d tn thng trong chn thng. Cc tng c d b chn thng hn cc
tng rng tuy nhin nu cc tng rng b tn thng, dch ng tiu ha s
i vo bng gy cc bin chng rt nng nh vim phc mc cp, sc nhim
khun.
Chn thng bng c th l chn thng kn hoc h. Ti khoa cp cu,
chn thng bng kn gp nhiu hn chn thng bng h, tuy nhin chn
thng bng kn cng khng km chn thng bng h v mc nng v t
l t vong.
Chn thng bng kn thng d b b st nu c cc chn thng
khc i km nh hn m do chn thng s no, gy chi chy mu nhiu
Khi bnh nhn c chn thng ngc vng thp ( t 2 nm v tr
xung) cn ngh n v phi loi tr chn thng bng i km.
Trong chn thng bng kn, Lch l tng hay b tn thng nht, sau
n gan v cc tng khc theo th t sau:
- Thn
- Rut non
- Bng quang
- i trng
- Ty
II. CHN ON
87
Bnh nhn c yu t chn thng ( tai nn giao thng, ng cao, tai nn

lao ng, xung t) i km cc triu chng lm sng sau cn ngh n chn
thng bng:
2.1.1. Cc triu chng bng:
- au bng, bun nn
- Nn ra mu
- Phn ng thnh bng, cm ng phc mc
- Bng chng
- Co cng c thnh bng
- Vt bm tm xy st thnh bng
- Vt xuyn thu bng
- Vt thng bng h
- Phi tng bng ra ngoi
2.1.2. Cc du hiu ngoi bng gi chn thng bng
- Triu chng mt mu khng ph hp vi mc mt mu ngoi
- Sc khng tng xng vi mc chn thng
- Vt thng, chn thng vng thp ca ngc
- Gy xng sn 7-9
- Chn thng xng chu
2.2. Cc thm d cn lm sng
2.2.1. Siu m bng cp cu:
- y l thm d khng xm nhp c th tin hnh ngay ti khoa cp
cu
- C gi tr pht hin dch, mu trong bng
- Pht hin c tn thng cc tng c: gan, lch
- Kh pht hin cc thng tn c honh, tng rng hoc tn thng
ty.
2.2.2. Siu m chn thng nhanh (Focused assessment with
sonography for trauma, FAST)
- Mc ch ca FAST l pht hin dch t do trong:
+ Khoang gan thn
+ Khoang lch thn
+ Ti cng Douglas
+ Mng ngoi tim
88
- u im:
+ Nhanh, khng xm nhp, c th tin hnh nhiu ln
+ C th tin hnh ti khoa cp cu cho bnh nhn nng, nguy kch
- Nhc im: ch pht hin c khi lng mu/dch trong bng >
100ml
+ Kt qu m tnh khng loi tr c chy mu trong
+ Kh xc nh trong trng hp vng hi, bo ph
- Bnh nhn khng n nh:
+ FAST dng tnh: m bng ( phng m)
+ FAST m tnh: tm cc ngun chy mu khc
- Bnh nhn n nh:
+ FAST dng tnh: CT bng
+ FAST m tnh: lm li sau 20-30 pht
2.2.3. Chc ra thm d bng
- Tin hnh ti phng cp cu: chc ra kn
- Thng ch nh khi khng c cc phng tin chn on khc nh:
Siu m, ct lp vi tnh
- Trc khi tin hnh th thut cn t sonde d dy v sonde tiu
- V tr chc: ng trng gia, di rn 0,5 cm
- Nn chc bng catheter, rt kim sau khi lun catheter vo bng
- Nu ht c > 10ml mu : dng tnh
- Nu m tnh, bm 1000 ml nc mui sinh l m vo bng sau
ht dch ra gi xt nghim. Chn on chy mu trong bng khi c >
100000 HC/ml hoc > 500 bch cu/ml
- Kt qu chc ra thm d bng khng loi tr c cc tn thng
sau phc mc v c honh.
2.2.4. Chp x quang ngc, bng
C th pht hin:
- Gy xng sn,
- Trn dch trn kh mng phi
- Tn thng xng chu
- Lim hi bng: v tng rng ( chp t th ng)
2.2.5. Chp ct lp vi tnh bng
- C gi tr trong chn on chn thng, nht l chn thng bng kn.
89
- Cn cn nhc ch nh chp nu bnh nhn trong tnh trng huyt

ng khng n nh.
2.2.6. Cc xt nghim cp: cng thc mu (Hng cu, hematocrite,
hemoglobine ), kh mu, nhm mu, nc tiu ( tm hng cu niu)...
III. X TR CP CU
3.1. Thm khm th u ( primary survey)
nh gi v x tr theo trnh t cc bc ABCD. nh gi nhanh (2
pht), tin hnh x tr ngay sau khi pht hin tn thng v nhc li nh gi
bt c lc no khi bnh nhn khng n nh.
Airway (A): ng th
- Xc nh c hay khng tc nghn ng th.
- Lu tn thng ng h hp trn.
- Nu c tc nghn phi x tr ngay, m bo ng th thng thong.
- Kim sot ng th t c bn n nng cao:
+ Ht sch mu m di, mc d vt
+ n c nhc cm hoc n hm
+ t canuyl ming hu hoc mi hu
+ t Ni kh qun, mt n thanh qun, ng kt hp.
Breathing (B): H hp
- Pht hin v x tr ngay ngay cc du hiu v nguyn nhn gy suy h
hp cp
- Oxy liu php : qua knh mi hoc cc loi mt n
- H tr h hp :
+ Bp bng qua mt n
+ Thng kh nhn to xm nhp v khng xm nhp
- Dn lu dch, kh mng phi nu c ch nh
Circulation (C): Tun hon
- X tr: chy mu ngoi ( nu i km chn thng bng)
+ Bng p cm mu, garo.
+ Bt ng chi gy
- X tr sc:
+ Hi sc dch : t hai ng truyn ln, truyn dch tinh th, dung
dch cao phn t, mu v cc ch phm mu nu cn
+ u thp chn cao, m
90
+ t ng truyn TM trung tm, dng thuc vn mch sau khi b

dch
+ u thp chn cao, m
+ t hai ng truyn tnh mch c ln (16-18G) hoc ng truyn
trc xng chy
+ Truyn dch tinh th, dch cao phn t, mu v cc ch phm mu
nu cn
+ t ng truyn tnh mch trung tm, truyn dch v theo di CVP
+ Cn nhc s dng cc thuc vn mch khi b dch m khng nng
c huyt p, tuy nhin trong hon cnh chn thng cn trnh huyt p
tm thu > 100 mm Hg v c th lm tng chy mu
+ Hi chn chuyn khoa ngoi cng sm cng tt, chuyn phng m
x tr chy mu trong
Disability (D): Tnh trng thn kinh
- im Glasgow
- ng t
- S dng k thut log-roll nh gi ton b ct sng v cc tn thng
pha lng
Exposure (E): Bc l
- Ci b qun o bnh nhn khm t u n chn, khng b st tn
thng, nht l cc vt thng pha lng, tht lng
- Gi m
- Gim au (nu cn)
2. Thm khm th hai ( secondary survey)
- Hi tin s, bnh s
- Bc l khm ton thn
- Mi chuyn khoa ngoi hi chn
- Tin hnh cc thm d khc:
+ Xt nghim mu
+ Siu m bng
+ Chp XQ ngc, bng
+ CT bng
+ Chc ra thm d bng
- Chuyn phng m theo kin chuyn khoa ngoi
- Vt thng phi tng:
91
+ Khng c c gng nht tng vo bng,

+ p gc lm m bng nc mui sinh l v khun, bng v chuyn
phng m
- Vt thng xuyn thu bng:
+ Khng rt vt xuyn thu ra khi bng ti khoa cp cu.
+ C nh chc chn vt xuyn thu v chuyn phng m
- Vt thng bng h:
+ Kch thc vt thng khng phn nh c tn thng bn trong
+ Khng thm d vt thng ti khoa cp cu.
+ Bng li, chuyn phng m.
+ Vic thm d vt thng phi c tin hnh ti phng m do cc
phu thut vin thc hin.
TI LIU THAM KHO
1. Heena P. Santry and Marc de Moya. Trauma Resuscitation.
Penetrating Trauma. 2012
2. Suresh Agarwal, Lejla Hadzikadic, and Peter Burke. Hypotensive
Resuscitation
in Penetrating Trauma: Rules of the Game. Trauma
Resuscitation. Penetrating Trauma. 2012
CU HI LNG GI
1. Khi chn on chn thng bng, thm d bng no sau y
khng c tin hnh ngay ti khoa cp cu
A. Chc ra thm d bng
B. FAST
C. Thm d vt thng bng h
D. Tt c cc bin php trn
2. Mc tiu x tr chn thng bng ti khoa cp cu l
A. Chng sc
B. X tr bo m ABC
C. Ly b vt xuyn thu khi bng
D. Chuyn bnh nhn vo phng m cng sm cng tt
92
E.A v B
3. Mt bnh nhn vo cp cu vi vt thng phi rut bng, bnh
nhn ku la d di, vic u tin cn lm l:
A. nh gi v x tr ngay tng phi ra khi bng
B. Siu m bng cp cu
C. nh gi v x tr ABC
D. Chp CT bng
Bi 12
CHN ON V X TR CP CU BAN U
SC CHN THNG NGI LN
MC TIU
1. Trnh by c cc nguyn nhn gy sc chn thng

2. Trnh by c ch bnh sinh ca sc chn thng v phn loi sc
mt mu
3. Trnh by c chn on sc chn thng
4. Trnh by c cc bc kim sot chn thng
NI DUNG
I. I CNG
93
Sc l mt tnh trng gim ti mu t chc, vi nhiu hin lm sng nh

ri lon huyt ng v suy tng. cp t bo, sc l hu qu ca thiu ht
chuyn ha c bn, c bit l oxy dn ti chuyn ha ym kh.
Trong chn thng, mt mu l nguyn nhn thng gp nht dn n sc.
Cc nguyn nhn tham gia vo thc y qu trnh ny gm c thiu oxy, tc
nghn c hc (p tim cp, trn kh mng phi p lc), chn thng ct sng
c nng v suy tim. Sc l mt nguyn thng gp v c th cu sng c
cc bnh nhn chn thng v nguyn nhn gy t vong ng hng th hai
sau chn thng s no trong chn thng
II. SINH L BNH V PHN LOI
1. Sinh l bnh
Bt tng xng gia cung cp v nhu cu xy l c ch tin pht ca sc.
p ng b tr ca sinh l mt mu l c gng m bo cung cp oxy m.
Kch thch h thn kinh giao cm dn n tng nhp tim, co mch v tng co
bp c tm tht.
Khi sc din tin, ti mu cc tng quan trng ( tim, no) c u tin
m bo v gim cc c quan khc ( da, rut, thn). Nu qu trnh ny
khng c khi phc dn n toan chuyn ha nng hn, do tng lactat mu,
cng vi thiu oxy l nguyn nhn dn n mt kh nng co mch ngoi vi v
try mch.
Hng nm, trn ton th gii c hn 2,5 triu ngi cht do chn thng
nng v cc tai nn giao thng. Hu ht cc trng hp cht do chn thng
xy ra trong nhng gi u sau chn thng, 34 50% t vong xy ra ti cc
bnh vin. Kim sot ti u chn thng c th lm gim phng trnh c
t vong ln n 76%.
2. Phn loi. Theo Advanced Trauma Life Support (ATLS)
Chia sc mu mu do chn thng thnh 4 loi vi cc c im nhn
mch triu chng sm ca tnh trng sc. Lu , Trong chn thng huyt p
ch h thp khi mt qu 30% th tch mu ca c th.
CH
S
II
III
IV
Ln
g
mu
mt
(ml) 1
<
750
7501500
1500
2000
>200
0
Ln
g
mu
mt
(%t
<
15%
1530%
3040%
>40
%
94
ng
ln
g
mu)
Nhp
tim
(ln/
pht)
<
100
>100
>120
>140
Huy
t p
Bnh
th
ng
Bnh
th
ng
p
lc
mch
(mm
Hg)
Bnh
th
ng
hoc
Nhp
th
(ln/
pht)
1420
2030
3040
> 35
Nc
tiu
(ml/h
)
thc
B
dch
>30
2030
5-15
Khn
g
ng
k
Hi
lo
lng
Lo
lng,
kch
thch
Kch
thch
v
ln
ln
L
ln
v l
Tinh
th
Tinh
th
v
mu
Tinh
th
v
mu
Tinh
th
III. TRIU CHNG LM SNG

1. Triu chng lm sng
Mt mu l nguyn nhn thng gp nht trong sc chn thng. Cc v tr
c th chy mu nng: trong bng, khoang sau phc mc, khoang mng
phi v mt mu ra ngoi.
Phi nhn bit sc chn thng t trc khi c du hiu tt huyt p. Cc
du hiu ca sc chn thng ty thuc vo tc , th tch v thi gian chy
95
mu. Ngoi ra cn c cc triu chng cp tnh khc km theo nh: trn kh

mng phi, thiu mu c tim
- Cc triu chng ca mt mu:
+ Mch nhanh, nh, huyt p h
+ p lc tnh mch trung tm thp
+ Da nim mc nht nht, lnh. u gi c mng tm nu mt mu nhiu.
+ Tim mi v u chi thng kh thy khi mt mu nhiu
+ Khm lm sng tm sot cc tn thng, nguyn nhn v v tr chy
mu: trong bng, trong c, khoang sau phc mc, mng phi
- Cc biu hin khc:
+ Vt v, l , ri lon thc, hn m. Cc ri lon thc c th do sc,
cng c th do say ru hoc lin quan n chn thng s no
+ Th nhanh, kh th, suy h hp
+ Kht nc, i t, v niu (lng nc tiu < 0,5 ml/kg/h)
+ H thn nhit
+ Gy xng.
Sc chn thng khng do mt mu thng kh chn on ( p tim cp vi
tam chng Beck: tt huyt p, tnh mch c ni v ting tim m thng biu
hin mun).
Trn kh mng phi p lc thng c biu hin: suy h hp, mt r ro ph
nang mt bn, trn kh di da, kh qun b y lch v mt bn, tt huyt p
l hu qu ca gim tin gnh do chn p vo tnh mch ch di.
nhng bnh nhn chn thng ty c cao c th gp sc thn kinh. Tt
huyt p thng nh, hu qu ca gim trng lc mch ngoi vi.
2. Cn lm sng
- Xt nghim cng thc mu v ha sinh c bn, bicarbonate v
lactat mu.
- Siu m bng
- Xquang hoc ct lp vi tnh: ngc, bng, khung chu
3. Chn on phn bit
Mt mu l nguyn nhn thng gp nht trong sc chn thng.
Cn phi chn on phn sc mt mu vi:
- p tim cp
- ng dp phi
- Nhi mu c tim cp
- Tc mch m hoc mch hi
IV. KIM SOT CHN THNG
1. Cp cu ngoi vin
96
Vn chuyn nhanh bnh nhn ti bnh vin l quan trng v khng lm

mt thi gian vo nhng thao tc tha.
- Ba nhim v quan trng cn phi lm:
+ i vi tng nn nhn: pht hin cc chn thng nng v chn
thng e da tnh mng
+ i vi nhiu nn nhn: Phn loi ( triage) cc iu tr ngay lp tc
cu sng nn nhn
+ m bo ng th, h hp tun hon v vn chuyn ti bnh vin
iu kin chn on, iu tr a chn thng
- Cn tm kim cc triu chng gim ti mu t trc khi c tt huyt
p.
2. Kim sot ban u sc chn thng
- Nguyn tc iu tr: tp trung vo:
+ Hi phc th tch lng mch
+ Th oxy
+ Cm mu
- nh gi v iu tr chn thng phi c thc hin ng thi (phc
). nh gi theo trnh t A ( Airway), B (Breathing), C ( Circulation) v
tnh trng chy mu v can thip ngay lp tc:
+ Np c nh ct sng c
+ Ti u ha oxy mu
+ t ng truyn ln truyn dch
+ Cm mu
+ Ly mu lm xt nghim v nh nhm mu
2.1. Cm mu
- Bng p nu c chy mu ra ngoi hoc dng clam kp cc mch
mu khi nhn thy, khng kp m.
- Gar cm mu trong ct ct chi, c bit khi cc bin php khc
khng th cm mu c. trnh thiu mu, ga r phi c ni lng nh
k ( sau mi 45 pht).
- Siu m nh gi dch bng, tm ngun chy mu. Siu m thay th
cho phn ln trng hp chc ra bng.
- Gy xng chu mt vng v chn thng mch mu l nguyn nhn
dn n sc mt mu. Bt ng c nh xng chu lm gim chy mu.
2.2. B dch
- B 2000 ml dch NaCl 0,9% qua ng ngoi vi ( kim lun 16G )
hoc catheter tnh mch trung tm. Ngoi ra c th dng dung dch cao phn
t.
- Truyn ngay ch phm mu nu c. Truyn mu vi t l huyt tng
/ khi tiu cu / khi hng cu = 1/1/1
- Mc tiu ca hi sc dch da vo p ng ca bnh nhn. Huyt p
trung bnh (HATB) khong 65mmHg v huyt p tm thu khong 90 mmHg
97
tr trng hp c chn thng s no km theo phi a HATB > 105

mmHg v huyt p tm thu > 120 mHg.
2.3. Thuc vn mch
S dng thuc vn mch sm ngay t u, khi cha b dch trong
sc mt mu thng lm nng hn.
3. Kim sot sc chn thng khng do mt mu
- Trn kh mng phi: thng c c chn thng ngc kn v chn
thng thu ngc.
+ X tr trn mu hoc trn kh mng phi do chn thng: t dn lu
ln ( 36F)
+ X tr trn kh mng phi p lc c tt huyt p: ngay lp tc ht dn
lu kh bng kim 12 hoc 14 G, v tr chc khoang lin sn 2 ng gia
n.
- p tim cp: c th do chn thng thu ngc hoc chn thng ngc
kn nng
+ Chn on : siu m ti ging c th thc hin ngay lp tc, nhanh
chng v chnh xc.
+ X tr: chc tho dch mng tim. Khi khi phc c huyt p, tnh
trng lm sng ci thin cn ch nh m ngc cp cu dn lu mu
khoang mng tim
4. Theo di: m bo cc ch s:
- Huyt p: HATV > 65 mmHg trong chn thng h v > 105 mmHg
i vi chn thng kn.
- Nhp tim: 60 100 ln/ pht
- Bo ha oxy ( SPO2): > 94%.
- Nc tiu: duy tr > 0,5 ml/kg/h
- CVP: 8 12 mmHg
- Lactat , kim thiu ht v bo ha oxy mu tnh mch trn: theo
di mi 4h m bo ti mu tng thch hp hoc ci thin khi hi sc.
- Truyn mu:
+ Truyn 2 n v khi hng cu nu hemoglobin (Hb) < 80g/l nu
bnh nhn khng c nguy c mch vnh cp hoc nu Hb < 100 g/l nu c
nguy c bnh mch vnh cp
+ Truyn mt khi tiu cu my hoc 6 n v tiu cu thng khi tiu
cu < 50 G/l
+ Truyn 2 n v huyt tng ti ng lnh khi INR > 2
+ Truyn 10 n v cryo nu fibrinogen < 100 mg/dl
98
TI LIU THAM KHO

1. Garcia A. Critical care issues in the early management of severe
trauma. Surg Clin North Am. 2006 Dec;86(6):1359-87.
2. Christopher Colwell. Initial evaluation and management of shock in
adult trauma. Uptodate 2013
CU HI LNG GI
Cu 1. Chn on sc chn thng da vo:
A. Tt huyt p
B. Da lnh v ni vn tm
C. Nc tiu di < 0,5 ml/kg/h
D. Tt c cc iu trn
Cu 2. Chn on phn bit sc mt mu trong chn thng:
p tim cp
A. Trn kh mng phi p lc
B. ng dp phi
C. Nhi mu c tim cp
D. Tc mch m hoc mch hi
E. Tt c cc trn
Cu 3. Kim sot ban u sc chn thng
A. Hi phc th tch lng mch
B. Th oxy
C. Cm mu
Cu 4. Mc tiu ca hi sc dch
A. Huyt p trung bnh (HATB) 65mmHg
B. HATB > 105 mmHg v huyt p tm thu > 120 mHg
C. HATB 105 mmHg v huyt p tm thu 120 mmHg khi c chn
thng s no
D. a v c
99
Bi 13
CP CU CHN THNG XNG, M MM V CHI TH T RI
MC TIU
1. Nu c cc nguyn tc chung x tr cp cu gy xng
2. M t mt s bin php c nh cc xng gy v nguyn tc x tr
cp cu chn thng xng chu
3. Nu c cc bc x tr cp cu vt thng t ri
4. M t triu chng lm sng v nu c nguyn tc x tr cp cu
hi chng chn p khoang
NI DUNG
I. I CNG
Chn thng xng v m mm c bnh cnh rt a dng:
- Chn thng khu tr: gy mt chi, rch, dp nt c ca mt chi
- a chn thng: gy xng chu, xng i kt hp vi chn thng
ngc bng, s no
- Chn thng xng kt hp chn thng m mm mt hoc nhiu
v tr
- Chn thng xng: gy xng kn, h, trt khp, sai khp
- Chn thng m mm: rch, dp nt c v t chc, vt thng t ri,
hi chng khoang
Phm vi bi ny ch yu cp n chn thng xng v m mm
chi, gy xng i v gy xng chu. i vi chn thng xng u, ct
sng tham kho phn chn thng s no v chn thng ct sng.
II. GY XNG
2.1. Nguyn tc nh gi v x tr cp cu bnh nhn chn thng
xng
- Bt ng ct sng c
- nh gi v x tr ng th H hp Tun hon (ABC)
- Cm mu nu c chy mu ngoi: bng p, gar
100
Xng sn
125 ml
Xng quay hoc

tr
250 500
ml
Xng cnh tay
500 750
ml
Xng chy, mc
500
1000 ml
Xng i
1000
2000 ml
Xng chu
1500
3000ml
Lng mu c th mt trong cc loi gy xng

- Chng sc:
+ u thp chn cao, m
+ t hai ng truyn tnh mch c ln (16-18G) hoc ng truyn
trc xng chy
+ Truyn dch tinh th, dch cao phn t hoc mu, v cc ch phm
mu
- Khm chn thng ton thn, khng b st tn thng
- Bt ng chi gy
- Gim au
- Lm cc xt nghim thng quy, ti ging: cng thc mu, sinh ha
- Khi tnh trng bnh nhn cho php, tin hnh cc xt nghim v thm
d khc: XQ, siu m, ct lp vi tnh..
- Hi chn chuyn khoa chn thng, b bt hoc phu thut nu c ch
nh
2.2. Gy xng
- Cc du hiu gy xng:
+ Bin dng chi
+ Gp gc, mt cu trc gii phu
+ Bm tm dp nt chi
+ Ngn chi
+ Sng n
101
+ au chi, mt vn ng
+ S nn tng cm gic au, c ting lo xo
+Trong gy xng h, c th thy u xng l ra ngoi gy
- X tr: ngoi cc nguyn tc x tr chung nu trn cn tin hnh bt
ng chi gy, gim au, chp XQ xc nh tn thng sau hi chn
chuyn khoa ngoi chn thng quyt nh bin php iu tr.
- Nguyn tc c nh chi gy
+ nh gi: mch cm gic vn ng ca chi trc v sau khi c nh
+ Bc l, nh gi (c th chp nh) vng tn thng trc khi c nh
+ Gy xng: bt ng 1 khp trn v 1 khp di xng gy
+ Tn thng khp: bt ng xng trn v di khp tn thng
+ Ra sch, bng p, cm mu vt thng xng khp h trc khi c
nh
+ Khng c nht phn xng h tr li vo trong da
+ Bt ng chi gy t th chc nng hoc t th bnh nhn thy d
chu
+ Nu chi b bin dng, gp gc nhiu, khng bt c mch di v tr
tn thng, chi tm, lnh c th ko nn tr li t th gii phu trc khi c
nh. Nu phi nn chi tr li t th gii phu, cn dng thuc gim au, dn
c va nn va ko dn. Khi ko cn dng lc nh nhng, khng c nn khi
b vng hoc b mc.
+ Np c nh cn c m lt m c bit hai u np
+ Nhc cao chi sau khi bt ng ( nu khng c chng ch nh)
- Gy xng, khp h
+ Ra sch vt thng bng nc mui sinh l v khun, ct lc nu
cn
+ Bng p cm mu, nu bng p khng cm c mu tin hnh garo
pha trn tn thng
+ Chp nh hoc ghi chp li tn thng
+ Bng kn vt thng h
+ nh gi mch cm gic, vn ng ca chi b thng
+ Nn tr li t th gii phu (nu c th)
+ Nu c cc vt xuyn thu vo chi, xng, khp, khng c rt ra
ti khoa cp cu, c nh chc, chuyn x l ti phng m
+ Bt ng bng cc phng tin c nh
+ nh gi li mch cm gic, vn ng
102
+ Tim phng un vn v khng sinh d phng

+ Hi chn chuyn khoa ngoi cng sm cng tt
2.3. C nh mt s gy xng thng gp
2.3.1. Bt ng xng n v xng b vai: Dng bng thun rng 1012cm bng c nh 2 xng n bt cho sau lng nh hnh s 8.
Bng s tm c nh xng n
2.3.2. C nh xng sn: nu ch gy xng sn n thun, khng
c mng sn di ng, khng c chn thng ngc. Ch cn gim au cho
bnh nhn, vo vin theo di, xut vin sau khi c kin hi chn chuyn
khoa ngoi.
2.3.3. C nh xng cnh tay:
- t hai np
+ 1 np bn trong, u trn ln ti h nch, u di qu khuu tay.
+ 1 np bn ngoi, u trn qu mm vai, u di qu khuu tay
- Sau bng c nh li buc p cnh tay vo ngi.
- Dng bng tam gic treo tay nn nhn v buc c nh vo trc ngc,
C nh xng cnh tay

2.3.4. C nh xng cng tay
+ Nu khp khuu co c, cnh tay st thn mnh, cng tay vung
gc vi cnh tay, sau bt ng
+ Nu khp khuu khng co c, cnh cng tay thng, sau c
nh
103
C nh xng cng tay

2.3.5. C nh c tay, bn tay
2.3.6. C nh xng ngn tay
2.3.7. C nh xng cng chn

+ t 2 np mt trong v mt ngoi chi gy, i t gia i ti qu c
chn. Nu c np th 3 th t mt sau cng chn
+ Bng c nh np vo chi bn c chn, di v trn khp gi, gia
i.
104
Bt ng xng cng chn bng np

2.3.8. C nh gy xng i: Dng 3 np c nh
+ Np mt ngoi i t h nch n qu gt chn.
+ Np mt trong i t bn n qu gt chn
+ Np mt sau i t trn mo chu n qu gt chn
+ Bng c nh np vo chi bn chn, c chn, 1/3 trn cng chn,
trn gi, bn, bng v di nch.
+ Buc chi gy c nh vo chi lnh
Bt ng xng i bng np
Nu khng bt c mch di ch tn thng, phi dng np ko lin

tc ( np thomas, Sager, hare)
105
Np Hare
Np Sager
Np Thomas
2.4. Chn thng xng chu

- V xng chu l mt chn thng nng thng nm trong bnh cnh
a chn thng.
- Lng mu mt do v xng chu c th rt ln ( c th ti 3000ml
hoc hn) v vy nguy c sc mt mu rt cao
- T l t vong trong chn thng xng chu km sc mt mu c th
ln ti 50%, v vy vic nh gi v h tr tun hon c vai tr cc k quan
trng
- Cc triu chng gi chn thng khung chu
+ au vng h v, tiu khung, au xng chu
+ Vt bm tm quanh rn
+ Vt bm tm dc hai bn sn
+ S nn khung chu c im au chi,
+ p nh 2 cnh chu: au, mt vng
+ Thm trc trng, m o c mu
+ Niu o r mu
- Mc tiu x tr gy xng chu ti khoa cp cu:
+ Hi sc ABCD, c bit lu h tr tun hon chng sc truyn
mu sm nht c th
+ Khm chn thng ton din, khng b st cc tn thng khc
+ Bt ng khung chu bng cch s dng mt tm vi ( c th ly ga
tri ging gp li c b rng bng khong cch t gai chu trc trn n
xng mu) qun quanh khung chu v buc cht.
+ Hi chn chuyn khoa chn thng, chuyn phu thut cng sm
cng tt khi c ch nh
106
2.5 Hi chng khoang

- Hi chng chn p khoang ( gi tt l hi chng khoang) l tnh trng
tng cao p lc trong mt khoang gii phu dn n s suy gim tun hon v
thiu mu cc b trong khoang, nu ko di gy ra cc thng tn ca cc
tng trong khoang.
- Khi nhc n hi chng khoang, ngi ta thng ngh n hi chng
khoang chi do chn p gia cc lp cn mc gy tn thng c v thn kinh
trong khoang. Tuy nhin hi chng khoang cn c th xut hin khoang
mng phi, mng tim, mng bng. Trong phm vi bi ny ch cp n hi
chng khoang chi lin quan n chn thng
- Nguyn nhn thng gp:
+ Bng, np, b bt qu cht
+ Chy mu trong khoang do vt thng mch mu
+ Bng
+ Vim sng ty cc b c
+ Tn thng phi hp gy xng, chn thng rch c
- Mc thi gian
+ Chn p khoang cp tnh c th xut hin t gi th hai n 6 ngy
sau chn thng
+ Chn p khoang ko di 6 gi gy hoi t c
+ Thi gian gii p m vn gi c chi an ton l trong khong 6-13
gi.
+ Sau 15-36 gi, phu thut gii chn p khng an ton, thng d gy
bin chng
+ Sau 36 gi thng phi ct ct chi
- Du hiu lm sng
+ au nhc t nhin khu tr vng khoang b chn p, vi tnh cht
au d di, nh c mch p, dai dng. Khng p ng vi cc loi thuc
107
gim au, bt ng chi gy khng lm gim au. Vn ng lm cng c gy

tng au
+ Sng, cng phng vng b chn p, s chm vo gy au d di.
+T b vng da do dy thn kinh nm trong khoang chi phi, sau
gim cm gic v mt cm gic (du hiu mun)
+ Da vng chi ti
+Khng bt c mch di vng tn thng (du hiu mun)
- Nguyn tc x tr hi chng chn p khoang ti khoa cp cu
+ ABCDE
+ Chn on sm hi chng khoang
+ Tho hoc ni bng, np, bt qu cht
+ Gi chi ngang mc tim
+ Khng sinh d phng
+ Gim au
+ iu tr v theo di hi chng tiu c vn cp
+ Hi chn chuyn khoa ngoi, rch cn c gim p cng sm cng tt
khi c ch nh
2.5. Trt khp
- Lm sng
+ Lin quan n chn thng
+ au, sng vng b tn thng
+ Khp b tn thng mt vn ng.
+ Du hiu l xo: khi lm ng tc th ng thay i t th bin dng
ca chi, khi bung tay ra th v tr chi th li tr li t th bin dng ban u
+ Du hiu bin dng: Thay i hnh dng cc khp, y l du hiu
chc chn d nhn bit v rt c gi tr trong chn on.
+ khp rng.
- Nguyn tc x tr:
+ nh gi v bo m ABC
+ C nh nh c nh xng gy
+ Tin hnh cc xt nghim v thm d chn on hnh nh chn
on xc nh v a ra k hoch iu tr
+ Gim au
+ Hi chn chuyn khoa v nn chnh khp sm
III. X TR VT THNG T RI
108
3.1. Phn loi

- Vt thng t ri hon ton: phn chi t ri v mm ct hon ton
khng c bt c cu trc gii phu no lin kt vi nhau
Vt thng t ri hon ton

- Vt thng t ri khng hon ton: phn chi t ri v mm ct cn
cu trc gii phu ni vi nhau: xng, cn c
Vt thng t ri khng hon ton

3.2. X tr cp cu chung:
- Bo m ABC
- t hai ng truyn ln h tr tun hon, chng sc
- Khng sinh d phng
- Tim phng un vn
- Xt nghim, thm d chn on hnh nh khi tnh trng bnh nhn
cho php
- Hi chn chuyn khoa ngoi chn thng x tr tip: ghp da, khu,
ni chi
3.3. X tr cp cu phn mm ct:
- Cm mu bng cch bng p hoc garo
- Dng nc mui sinh l v khun ra sch mm ct
- Ct lc nu bn hoc dp nt nhiu
109
- p gc tm nc mui sinh l v khun, bng kn mm ct

- Chm lnh u mm ct (khng tip xc trc tip vi mm
ct)
3.4. X tr phn chi th t ri:
- Ra sch bng nc mui sinh l v khun
- Qun gc tm nc mui sinh l v khun
- B vo ti nilon sch dn kn
- B ton b ti nilon trn vo chu nc
- Chuyn ghp ni chi ( phng m hoc chuyn tuyn trn)
3.5. Vt thng ct ct khng hon ton:
- Cm mu: bng p, garo
- Ra sch bng nc mui sinh l v khun
- t li t th gii phu
- p gc tm nc mui sinh l v khun, bng kn
- Np bt ng
TI LIU THAM KHO
1. Dave Hehemann, Mark Hardy. Keys to Optimal Management of
Open Fractures. American College of Foot and Ankle Surgeons. 2010
2. Anthony Brown and Michael Cadogan. Orthopaedic Emergency.
2011
3. Guideline for essential trauma care WHO 2004
4. Aneel Bhangu, Caroline Lee, and Keith Porter. Emergencies in
Trauma. Oxford University Press, 2010
CU HI LNG GI
1. Bin php x tr cp cu no sau y khng c tin hnh khi x
tr vt thng xng h
A. S dng khng sinh d phng
B. Ko nn chi gy tr li t th gii phu
C. St khun vt thng h bng Povidin 10%
D. Ra sch vt thng h bng nc mui sinh l 0,9%
2. Chn bin php cp cu ng nht bo qun phn chi th t ri
A. Cho vo ti nilon sch, bc li, cho vo chu nc
B. Ngm vo nc mui sinh l 0,9% bo qun nhit 4-8 C
110
C. Qun gc tm nc mui sinh l 0.9% v khun, b vo ti

nilon, cho vo chu nc
D. Qun gc v khun, cho vo chu nc
3. V xng chu l mt chn thng c nguy c e da tnh mng
bnh nhn ngay lp tc v l do no sau y:
A. Gy au nhiu
B. Gy vim phc mc
C. Sc mt mu
D. Kh hi phc
111
Bi 14
X TR CP CU BNH NHN BNG
MC TIU
1. Trnh by c cc nguyn nhn gy bng.
2. nh gi c tnh trng nguy kch ca bnh nhn ti khoa cp cu.
3. Phn nng ca bng (din tch, su, v tr).
4. Nm c cch x tr cp cho bnh nhn bng ti khoa cp cu.
NI DUNG
1. i cng
- Bng c xem nh mt loi chn thng trn da hay cc m khc.
Bng xut hin khi mt vi hay tt c cc t bo b tiu dit bi: sc nng,
lnh, in, phng x, hay cc tc nhn ha hc khc.
- Cp cu bnh nhn bng bao gm: nh gi du hiu nguy kch ti
tnh mng bnh nhn, nh gi tn thng bng, s cu v cp cu.
2. Chn on
2.1. Nguyn nhn gy bng
2.1.1. Bng do nng: bnh nhn tip xc vi dng c cha cht nng b
v, cht lng nng, nhng vt dng nng, hi nng
2.1.2. Bng do lnh: do tip xc vi bng lm bng t bo.
2.1.3. Bng do ha cht: bnh nhn tip xc vi mt s loi ha cht:
acid, kim mch hoc iod, phospho dng trong cng nghip vi ti
2.1.4. Bng do in: in git, st nh.
2.1.5. Bng do ht: xy ra khi c cc v n hay ht phi cc hi my.
2.1.6. Bng do phng x: nng lng phng x hay cc phng x gy
ra bng thng gp l "bng mt tri".
2.2. nh gi tnh trng nguy kch do bng gy ra
- thc: tnh to, hong ht, lo u, s hi, au n, vt v, hn m.
- Thn kinh: co git
- H hp: nn nhn b bng vng mt, c nht l khi b kt trong nh b
chy d b ph mt c v cc bin chng ng h hp do ht phi khi, hi,
kh c (xem xt s thng thong ng h hp, d vt chn thng ng h
hp km theo, nh gi tnh trng h hp, SpO2
112
- Tun hon: tnh trng sc: mch nhanh, huyt p tt, du hiu gim ti
mu.
2.3. nh gi nng ca vng bng: theo Wallace
- u 9%
- Thn mnh: trc 18%; thn minh sau 18%
- Chi trn 9%; chi di 18%
- B phn sinh dc ngoi 1%.
2.4. Chn on su ca bng
1: da, au (nh chy nng) rt do u mt dy thn kinh b kch
thch, loi bng ny thng lnh hn sau 3 ngy.
2a (nng) phng nc lan rng khp b mt vt bng, au nhiu, r
nc.
2b (su): au t hn 2a, c vng t, tn thng da dnh cht b
mt, n knh (+). So hnh thnh trong 3 tun, c th so su, hoc so li xu.
3: vng bng trng bng, ti hoc nu khng au, vng tn
thng bm cht, cn phi ghp da.
Cn ch nhng vng tn thng b che khut, xc nh nguyn nhn
gy bng: bng in, ha cht, nc si, la.
Bng ha cht: tin lng ph thuc vo vic ra sm, bng mt phi
c chuyn ngay cho chuyn ngnh mt.
3. X tr
3.1. Nguyn tc x tr
- m bo cc bc A, B, C trong x tr cp cu ngi bnh
- Nhanh chng loi tr cc tc nhn gy bng ra khi c th nu cn
- Hn ch ti thiu mc nhim bn cho vt bng, bng b vt
thng, vn chuyn n chuyn khoa bng.
3.2. Cc bc
3.2.1. Bc 1: nhanh chng loi tr cc tc nhn gy bng ra khi c
th nn nhn (nu cn): x b qun o ang chy m hoc b thm m nc
nng, xng, du, ha cht.
- Bc vng bng chc chn ri nc lnh ln
- Tho b nhng vt cng trn vng bng nh giy, ng, vng nhn
trc khi vt bng sng n.
- Che ph vng bng bng p gc vaseline
3.2.2. Bc 2: cp cu m bo cc chc nng sng
113
* m bo h hp: m bo s thng thong ng th ty theo tnh

trng suy h hp c th phi: th oxy mi mask, t ng ni kh qun, nu suy
h hp nng hn hoc ri lon thc, thng kh nhn to
* m bo tun hon:
- t ng truyn tnh mch ln, tt nht l ng thng tnh mch
trung tm.
- m bo th tch tun hon: natri clorua 0,9%, dung dch keo,
albumin 5%, dung dch ringerlactat, lu cn m bo tun hon ngay trong
1 - 3 gi u.
- Theo di mch, HA, nc tiu l theo gi l thng s quan trng nht
b th tch (phi m bo 1ml/kg/gi).
- Vi nhng bnh nhn tnh to, khng b nn v khng c nhng
chng ch nh do chn thng khc th c th cho bnh nhn ly nc theo
nhu cu (nc sch, dung dch oresol, nc hoa qu ti).
* Cc bin php cp cu khc
+ An thn, gim au: nu bng gy au nhiu thng dng morphin tim
di da xa ni bng, bng rng, au nhiu c th tim tnh mch (lu m bo
h hp).
+ Khng sinh: cn t ra, ch nguy c nhim trng ym kh: cc
khng sinh c th dng: Amoxicillin/clavulanat, nu bng rng, su nn cho
cephalosporin, aminoglycosid, carbapeneur, fluoroquinolon.
+ D phng lot ng tiu ha do stress: (dng c ch H2, PPIS).
+ Bng do chy, c ri lon thc, c tn thng tiu cu tim vitamin
B12 sau khi ly mu nh lng CO v CN
3.2.3. X tr cp cu vt bng
- Bng ch bng bng bng v khun: c th dng gc v khun bng
li hn ch ch mt nhit ca bnh nhn.
- Bng su: Rch ra bng tun hon mu c bnh thng trnh
thiu ti mu.
- Bng bn tay th cho bn tay vo ti nha ri bng lng c tay, lm nh
vy cho php nn nhn vn c ng c cc ngn tay d dng, trnh lm bn
vt bng.
- Bng c chn, c tay th ph vt vng bng gc v khun sau
c th np c nh.
- Khng chc ph cc ti phng nc.
- Khng bi du m, dung dch cn, km khng sinh vo vt bng.
3.2.4. Cp cu mt s trng hp bng c bit
114
- in git, st nh: Thng bng rt su v gy ngng tim, sau cp

cu ti hin trng nn nhn c a ti khoa cp cu c th vn c lon
nhp tim, cn theo di v x tr lon nhp.
- Bng ha cht: Mt s loi ha cht nh acid, kim mch hoc iod,
phospho dng trong cng nghip hoc vi nc ti c th gy nn tn thng
bng nng v lm nn nhn rt dau n: Vic x l ti hin trng m bo
khi n khoa cp cu cn phi :
+ Ra li lin tc bng nc cng nhiu cng tt, nu khng cc t
chc vng bng s hoi t hon ton, nu nguyn nhn gy bng l acid
th ra vt bng bng dung dch, bicarbonat, nguyn nhn l kim th ra
dung dch c pha gim, chanh.
+ Nu bng ha cht mt th ra bng nc sch.
+ Phi tho b qun o b dnh ha cht.
+ Nu bng chy mu nhiu th x tr nh vt thng chy mu.
Bc s khoa cp cu cn hi chn ngay vi bc s chuyn khoa su v
bng trong v sau khi thc hin cc x tr trn bnh nhn c hi sc v
iu tr theo chuyn khoa su v bng.
4. Tai bin v bin chng
4.1. Tn thng phi do suy h hp cp tin trin trong nhng ngy
u: Bng rng, ha cht, bng ng h hp, kh c.
4.2. Nhim khun, c bit vi bnh nhn bng nng, bng su.
5. Kinh nghim thc t
- Chn on su thng khng chc chn.
- Trnh iu tr ti ch lm thay i vng bng nh dng eosine, thuc
m, khng t cc vt liu thm ht ln vng bng, khng m bo v khun.
- Khng dng khng sinh d phng nht lot to dng vi khun khng
thuc.
- B dch phi theo hng dn, da theo bnh nhn c th, khng theo
cng thc cng nhc.
- Khng qun tim phng un vn.
- Lu cc trng hp bng ht phi kh c CO, CN (khi ngi bnh
b bng la trong mi trng kn c nhiu cht do chy).
TI LIU THAM KHO
1. V Vn nh (2009). Cm nang cp cu, Nh xut bn Y hc, tr
487-492.
2. Namias N (2007). Burn Care. Current Opinion Critical Care: 13:405.
3. Carsin H (2010). Current advances in the initial management of
major thermal burns. Intensive care medicine 26:848.
115
CU HI LNG GI
Cu 1: Tnh trng ca c th b phng ph thuc vo:
A. su ca bng
B. Din tch ca vt bng
C. V tr ca vt bng trn c th
D. C 3 trn
Cu 2: Cc nguyn nhn gy bng
A.
B.
C.
D.
E.
G.
Cu 3: Ng c kh c(CO, CN) hay gp trong cc trng hp
A. Bng la trong mi trng kn
B. Bng do in git, st nh
C. Bng ha cht (acid, bazo)
D. C 3 trn
Cu 4: Vic cp cu bnh nhn bng ti khoa cp cu bao gm cc vic quan
trng sau:
A. Nhanh chng loi tr tc nhn gy bng ra khi c th nn nhn
(nu cn)
B. m bo cc chc nng sng.
C. X tr cp cu vt bng.
D. Tin hnh v da cp cu.
E. C 4 trn.
116
Bi 15
NGUYN TC CHN ON, X TR NG C CP
MC TIU
1. Trnh by c cc loi ng c hay gp trong cp cu.
2. Nu c nguyn tc x tr cc loi ng c thng gp.
3. Trnh by c cc bin php x tr ng c cp.
NI DUNG
1. NGUYN TC CHUNG:
1.1. C 2 nhm cng vic:
1. Hi sc ton din v iu tr cc triu chng 2. Cc bin php chng
c c hiu:
1.2. Khi no lm g? Khi bnh nhn cha c triu chng (n sm): u
tin cc bin php chng c. Khi bnh nhn c triu chng: u tin cc
bin php hi sc v iu tr triu chng.
2. CC CNG VIC C TH:
2.1. Cp cu ban u hay n nh bnh nhn
Nhim v: ngay khi tip xc vi bnh nhn, trong vng vi ba pht u
tin, xc nh v thc hin ngay cc bin php cn tin hnh nhm bo m
tnh mng v n nh trng thi bnh nhn (khng bnh nhn cht trong
khi ang thm khm). Vic xc nh c thc hin bng: nhn bnh nhn,
s mch v lay gi bnh nhn. Cc tnh hung cn gii quyt ngay thuc v 3
h c quan sng cn : H hp, tun hon v thn kinh. C Th:
2.1.1 H Hp:
- Nu c suy h hp: th chm, ngng th, th nhanh nng , xanh tm,
v m hi, co ko cc c h hp, cn can thip h tr h hp.
- Mc ch can thip nhm: Khai thng ng th, bo m thng kh,
b xung oxy trong kh th vo bo m tnh trng oxy ho mu
- Cc bin php can thip: nga c, th oxy, ht m di, t canun
mayo, t ni kh qun, m kh qun, thi ngt, bp bng ambu, th my,
dng cc thuc gin ph qun
2.1.2. Tun hon:
C 2 tnh trng cn x l cp: lon nhp v tt huyt p.
- Lon nhp:
117
+ Nhp chm di 60 ln/pht: atropine 0,5mg tnh mch, nhc li cho

n khi mch > 60 ln /pht hoc tng liu = 2mg; Nu nhp chm khng ci
thin, thng km vi tt huyt p: truyn adrenaline TM 0,2 g/kg/pht,
iu chnh liu theo p ng.
+ Nhp nhanh: ghi in tim v x tr theo loi lon nhp: nhanh tht,
rung tht, xon nh: sc in kh rung; nhanh xoang, nhanh trn tht:
digoxin, prostigmin,
- Tru mach tt huyt p:
Trc ht xc nh c gim th tch tun hon khng; nu c truyn
dch bo m th tch. Khi loi tr gim th tch m vn tt HA th cho
thuc vn mch. Thng l Dopamin (5-15 g/kg/pht); nu tt HA do vim
c tim nhim c: dobutamin: bt u 10 g/kg/pht, tng liu nu cha p
ng, mi ln tng 10 g/kg/pht cho n khi t kt qu hoc t
40g/kg/pht; nu cn phi hp vi dopamin; nu tt HA do gin mch gim
trng lc thnh mch: Noradrenaline bt u 0,2 g/kg/pht, iu chnh theo
p ng. Phi hp thuc khc khi cn: thng l vi dopamin liu < 5
g/kg/pht v Adrenaline bt u 0,2 g/kg/pht. Khi dng thuc vn mch
phi c bm tim in, theo di st v iu chnh liu kp thi sau mi 15-30
pht nhanh chng t mc ch nng Huyt p vi liu thuosc vn mch
ti u.
2.1.3. Thn kinh: co git hay hn m?
- Co git: ct cn git bng cc loi thuc:
+ Seduxen ng 10 mg tim TM (tr em tim 1/3 n mt na ng) nhc
li cho dn khi ct c cn git. Sau truyn TM hoc tim bp duy tr
khng ch cn git. C th thay thuc duy tr bng gacdenal vin 0,1g ung
t 1 n 20 vin/ ngy tu theo mc co git.
+ Thiopental l 1g; Tim TM 2 - 4 mg/kg (bolus), nhc li cho n khi
ct cn git; duy tr 2mg/kg/gi (khng qu liu ny v c nguy c vim gan
nhim c); hoc thay bng gacdenal 1-20 vin/ ngy. iu chnh liu tu
theo bnh nhn. C trng hpp co git do ng c ho cht bo v thc vt
phi dng gardenal ko di hng thng, liu cao nht 2,4g / ngy (2 vin
mi 2 gi), gim dn sau 1 thng xung 1 vin/ ngy v duy tr tip nhiu
thng sau
- Hn m:
+ Glucose u trng 50% 50mlTM, sau truyn duy tr glucose 10%
1000ml/24 gi vi mc ch nui dng. Km vitamin B1 100mg tim bp
hoc tnh mch
+ Naloxol 0,4mg TM chm lai tr qu liu heroin
+ Bo m h hp chng tt li, ht phi tro ngc
118
2.2. Hi bnh, khm ton din, lm cc xt nghim. Chn on, lp

v thc hin k hoch iu tr.
2.2.1. Hi bnh:
Khong 95% chn on nguyn nhn ng c c quyt nh do hi
bnh; cn kin tr, hi ngi bnh, ngi nh, nhiu ln, nm c thng
tin trung thc. Yu cu ngi nh mang n vt chng nghi gy c( n
ung, v l, bao b thuc, ho cht)
Ngi bnh hoc ngi nh bnh nhn c th khng nh r, hoc ln
ln cc s kin hoc thm ch c tnh cung cp thng tin sai nhm nh lc
hng. V vy thy thuc phi lun lun i chiu bnh s vi thm khm
lm sng thu nhn c cc thng tin chnh xc.
Cn xc nh:
a. Nhim c u, khi no, ti sao nhim, nhim nh th no: nng,
nh, nhiu, t c cht), c ai khc chng kin khng.
b. xy ra cc triu chng, du hiu g sau khi nhim c (trc khi
gp bc s), v d nn, co git, hn m, ho, kh th
c. Cng vi c cht c n ung thm g khc khng, c ung nhiu
loi thuc khng?
d. c x tr, iu tr g cha?
e. Tin s bnh tt (ca bnh nhn v gia nh) nh th no? Bao gm
tin s d ng, cc bnh mn tnh c th tng tc vi c cht? cc tnh
hung xy ra trc khi nhim c (stress, n nn)
Nh
m C
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h
p
t
h
Kch
thch
N
h
i
t
h
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a
y
TK
giao
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(amp
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ectasy
119
n
g
t
C
o
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h
d
a
,)
An
thn,
ru
t
h
a
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giao
cm)
Antic
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C
o
p
h
t
h
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(atrop
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k
h
c
t
i
Choli
nergic
t
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y
(OP,
carba
mate)
C
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n
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i
t
d
c
h
,
120
y
c
Opiod
s
C
o
p
h
n
h
Thm
opioi
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n
,
h
o
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g
,
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Thm
ru
hay
thuc
121
n
,
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thn
(HC
cai)
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,
c
o
g
i
t
Bng 1.1: Tm tt mt s hi chng ng c
2.2.2. Khm ton din pht hin cc triu chng, tp hp thnh cc hi

chng bnh l ng c gip cho vic chn on nguyn nhn.
Vi cc BN c suy gim thc, cn chn on loi tr cc nguyn
nhn do tn thng cu trc (TBMN, chn thng s no...)
a. Hi chng thn kinh giao cm (Kch thch adrenergic): mch nhanh,
huyt p tng, th nhanh, nhit tng, ng t dn, da t, nim mc kh,
kch thch vt v, hoang tng, v d ng c amphetamine, cocaine,
ephedrine, phencyclidine.
b. Hi chng thn kinh ph giao cm bao gm: h huyt p, mch
gim, thn nhit gim, ng t co, gim vn ng co bp, phn x gn xng
- c gim, bnh nhn l m v hn m.
V d ng c nhm cc thuc ng (barbiturates) v an thn
(benzodiazepin), clonidine, mt vi thuc h p, ethanol, opioids.
c. Hi chng cholinergic (khng men cholinesteraza)
Du hiu Muscarine: mch gin, huyt p thay i, ng t co nh,
tng tit dch tiu ho, dch ph qun, ph nang, m hi.
Du hiu Nicotin: huyt p tng, mch tng, my c, yu v lit c
(c h hp).
Du hiu thn kinh trung ng: kch thch vt v. V d NC photpho
hu c, carbamates, physostigmine, nicotine.
d. Hi chng anticholinergic: mch nhanh, huyt p tng, nhit thn
tng, ng t gin, da nng , kh, gim co bp, vt v, kch thch phn x
gn xng tng. V d NC Atropine
e. Co git: co git ton thn, cc cn ngy cng mau v mnh: NC
vi nhiu loi thuc hay cht c nh thuc dit chut loi mono sodium
trifluoroactate v trifluoroacetamide, m tin, INH, phenothiazines,
theophylline, thuc chng trm cm vng, phencyclidine, strychnine.
122
f. H huyt p: Do NC nhiu loi nh: thuc iu tr tng huyt p,

theophylline, st, phenothizines, barbiturates, thuc chng trm cm, cc cht:
cyanide, carbon monocide, hydrogen sulfite, arsenic, nm c.
g. Ri lon nhp tim: Xut hin trong ng c cc thuc v cht c
sau :
- Nhp chm xoang: beta-blocker, verapamil, phospho hu c, digitalis
glycosides, opioids, clonidin, sedative-hyporotics.
- Block nh tht: beta-blocker, digitalis glycosides, tricyclic
antidepressants lithium, chn canxi, lithium.
- Nhp nhanh xoang: theophylline, cafeine, cocaine, anphetamine, kch
thch beta (salbutamol), antihistamine, anticholinergic, tricyclic
antidepressants, st.
- Phc b QRS dn rng: thuc chng trm cm tricyclic, quinidine v
mt s thuc chng ri lon nhp tim, phenothiazine, aconitin (c u tu),
tng K+.
+ QRS dn rng c th l hu qu ca thiu oxy hay ri lon in gii
nh tng, h kali mu, h Mg. Cn iu chnh trc nhng ri lon ny trc.
Nu nhng ri lon cn tn ti th dng lidocaine (xylocaine) v cc thuc
chng ri lon nhp tim khc v quan tm n cho dch NaHCO3 trong ng
c quinidine v thuc chng trm cm tricyclic.
2.3. p dng cc bin php hn ch hp thu
2.3.1. Cht c qua ng h hp a nn nhn ra khi ni nguy
him, vng thong kh.
2.3.2. Da, nim mc:
- Ci b qun o bn ln ha cht c, tm ra bng xi nc m v x
phng, gi u. Ch nu c nhiu ngi cng b ng c ha cht th phi
xi nc ng lot cng mt lc, trnh tr hon, i ch.
- Ra mt khi cht c bn vo: cn ra mt lin tc 15 pht bng
dng nc mui 0,9% chy lin tc trc khi a i khm chuyn khoa mt.
2.3.3. Cht c qua ng tiu ho
2.3.3.1. Gy nn: Ch nh: nu mi ung, n phi cht c v nn nhn
cn tnh to, cha c triu chng ng c. Chng ch nh: nn nhn l ,
hn m hay co git , ng c axt hay kim mnh. Gy nn bng cch: cho
nn nhn ung 100 200 ml nc sch ri dng tm bng, hoc ng xng
ngoy hng, ci thp u nn, trnh sc vo phi. Quan st cht nn, gi li
vo mt l gi xt nghim.
2.3.3.2. Ung than hot:
- Cho than hot vi liu 1g/kg cn nng ho trong 100 ml nc sch
cho nn nhn ung. Sau 2 gi c th ung nhc li nu thy cn.
123
- Km theo than hot bao gi cng phi cho sorbitol vi mt lng gp

2 ln than hot.
- C th ung hn hp than hot + Sorbitol ( Antipois - B. Mai ca
TTC ) ngi ln 1 l 120 ml, tr em 1/2 l 60 ml v tr em di 2 tui
khng dng.
2.3.3.3. Ra d dy:
- Hiu qu nht trong 60 pht u b NC
- Cn hiu qu trong 3 gi u v ung than hot
- Cn hiu qu trong 8 gi u vi ng c: tricyclic, phenobarbital,
salycylates, hoc ung mt s lng ln.
- Ch nh:
+ Hu ht cc thuc ung dng nc, bt vin, ming nh
+ Cho cc bnh nhn khng gy nn c
- Chng ch nh:
+ Sau ung cc cht n mn : acids, kim mnh.
+ Sau ung cc ho cht : du ho, t xng, paraffin.
+ Tuy nhin nu c k thut tht tt phng trnh cc bin chng vn c
th ra d dy.
+ Bnh nhn hn m, co git tr khi c t ng NKQ bm bng v
dng thuc chng co git.
- K thut:
+ Bnh nhn nm nghing tri, u thp.
+ Xng d dy c 37- 40F cho ngi ln; 26-35F cho tr con, bi trn
a qua ming hay mi vo ti d dy.
+ Nc a vo mi ln 200ml vi ngi ln, 100ml vi tr em, sc
bng ri tho ra. Khng dng my ht in. Nhc li nhiu ln cho ti khi
sch d dy.
+ Dng nc sch, m pha vi mui 5g mui/lt nc, tng s lng
nc ra thng 5 -10 lt vi cc trng hp ung thuc tr su, 3-5 lt nc
vi hu ht cc trng hp khc.
2.3.3.4. Nhun trng:
- Nhm kch thch co bp rut tng cht c ra ngoi. Thng dng l
sorbitol 1-4g/kg ung ngay sau dng than hot, hoc trn vo than hot.
2.4. Cc bin php tng thi tr c cht.
- Bao gm cc bin php: li tiu tch cc, ung than hot hng lot,
lc ngoi thn, thay huyt tng, thay mu. Ch thc hin bnh vin.
124
Li tiu tch cc: ch nh: ng c cc loi c cht c o thi

qua ng tit niu: gardenal. Seduxen, hoc tnh trng tiu c vn trong
ng c (ong t, rn h mang cn). Chng ch nh: suy tim, suy thn th
thiu niu hoc v niu. Thc hin: truyn dch vi tc 150-200ml/gi
ngi ln, 20- 100ml/gi tr em-ty theo cn nng v tng s dch truyn.
Dch truyn thng l dch ng trng (mt na l glucose 5%; mt na l
natri clorua 0,9%; nu l gardenal th truyn glucose 5%, natriclorua 0,9% v
natribicarrbonat 1,4% theo t l 2:2:1 vi khi lng ton b bng 50-80ml/kg
cn nng).
Theo di lng nc tiu theo gi > nu khng t 100-200 ml/ gi
cho ngi ln v 2-4 ml/kg cn nng cho tr em th cho thm thuc li tiu
mnh (furosemide). iu chnh lng dch truyn v thuc li tiu theo theo
lng nc tiu/gi.
Lc ngoi thn: khi li tiu tch cc khng c tc dng, hoc BN suy
thn, hoc c cht khng ha tan trong nc v khng thi qua thn. Ch
nh chng ch nh ph thuc vo bin php lc, v tng c cht ring.
Thng c p dng nht l Intermittent hemodialysis (HD) v lc
mu lin tc tnh mch tnh mch (CVVH); Lc mu hp ph (bng ct lc
than hot hoc ct lc resin ang c nghin cu trin khai ti Trung tm
Chng c
Thay huyt tng hoc thay mu: c th c ch nh khi cc bin
php thi tr khc khng c hiu qu v thc hin vo thi im c cht c
nng trong mu cao nht. V d ng c paraquat khi BN nhp vin trong
vng 2-4 gi u. bt u ng dng ti Trung tm Chng c v ang
c nghin cu.
2.5. S dng thuc gii c. (xem thm bi Thuc gii c
chng trnh Chng c chuyn su)
Thuc gii c l bin php iu tr c hiu qu cao, nu c dng
sm v ng cch, v vy cn d tr v tn dng thuc gii c trong iu tr
ng c cp.
2.5.1. inh ngha: Thuc gii c (antidote) l cc cht c tc dng
c hiu chng li tc ng hoc hiu qu c hi ca mt c cht
2.5.2. C ch tc dng
- Gii c qua tng tc ho hc
- Gii c qua tc dng dc l.
- Cnh tranh th cm th
- i khng tc dng
- Phc hi chc nng bnh thng
2.5.3. Vn liu lng:
125
Rt nhiu thuc gii c cha xc nh c liu ti u. cc liu

khuyn co thng da trn thc nghim trn sc vt v trn ngi khe
mnh bnh thng.
Ngi ng c s p ng khc vi ngi khc; v lng thuc gii
c phi tng ng ( trung ha c cht) hoc thm ch nhiu hn c
cht ( tranh chp th cm th, i khng tc dng, phc hi chc
nng).
Dng khng thuc gii c s khng c tc dng; ngc li dng
qu liu thuc gii c c th s tr thnh tc nhn gy ng c. V vy ngi
bc s iu tr phi quyt nh liu lng cho tng ngi bnh v theo di
cht phn ng ca ngi bnh khi dng thuc gii c.
Hin Vit Nam c mt s thuc gii c c hiu c phc iu
tr c th c kim chng qua lm sng: PAM v atropin trong ng c
phospho hu c; N Acetylcystein trong ng c paracetamol; Naloxon trong
qu liu thuc phin, D penicilamin v cc cht gp kim loi nng khc trong
iu tr ng c ch, huyt thanh khng nc cc loi rn: h cha, h mang,
cp nia, lc tre, chom qup
2.6. Cc bin php iu tr triu chng, hi sc ton din: gan, thn,
huyt hc, nc in gii. Gio dc phng chng ti pht trc khi ra vin.
TI LIU THAM KHO
1. V Vn nh v cng s (2002), Cc nguyn tc x tr ng c
cp, Hi sc cp cu ton tp, Tr. 348-356, NXB Y Hc, H Ni.
2. M. Ellenhorn, D.G. Barceloux (1988), General approach to the
poisoned patient, Medical Toxicology, 1st edition, Elsevier Science
Publishing Company, PP.1-102.
3. Richard C. Dart (2004), Initial Management of the Poisoned
Patient, Medical Toxicology, 3rd edition, Lippincott Williams & Wilkins, PP.
21-39.
CU HI LNG GI
Khoanh trn vo mt hoc nhiu ng:
1. X tr ng c cp gm:
A. 2 loi cng vic: hi sc v chng c
B. 6 nhm cng vic
C. Cn u tin hi sc
D. Cn u tin chng c
126
2. Chn on ng c cp quan trng nht v phn ln nht l da vo

A. Hi bnh v khm lm sng gip pht hin cc u mi
B. Chn on hnh nh
C. Xt nghim c cht
D. Xt nghim thng thng
3. Ch nh ra d dy:
A. Cho mi ng c qua ng tiu ha n trc 6 gi
B. Ng c ng tiu ha khng quan trng thi im n vin
C. Bnh nhn nghi n ung phi cht c n trc 2 gi, khng c
chng ch nh.
D. Khng c cu no ng
4. Than hot l
A. Than ci c nghin nh
B. Than nghin nh
C. Than c x l c bit c kh nng hp ph cao hu ht cc c
cht
D. Ch l cht bt mu en ging than
5. Thi x tr ng c cp
A. Trc ht l iu tr thuc gii c (nu c) theo kt qu xt nghim
c cht
B. Loi tr c cht bng cc bin php cn c lm ngay.
C. Ra d dy cho BN ng c ng ung cng sm cng tt.
D. Ch l iu tr triu chng
E. Khng c cu no ng
6. T th ca bnh nhn khi ra d dy
A. Nm nga n c
B. Nm nghing sang phi
C. Nm nghing sang tri, u thp
D. Nm thng
7. Bnh nhn ng c cp thuc ng, khi vn chuyn n bnh vin cn
nm t th:
A. Nm nga
B. Nm u cao
C. Nm u thp
127
D. Nm nghing an ton
8. Gy nn l bin php
A. C th tin hnh cho bt c bnh nhn ng c no
B. Ch tin hnh tr em
C. Ch tin hnh sau khi khng c than hot
D. Khng c cu no ng
9. Trc mt bnh nhn ng c, vic u tin l:
A. Trnh khng ly nhim cho ngi cp cu
B. Bo m cc chc nng sng cho nn nhn
C. Cho bnh nhn th o xy phng suy h hp
D. t mt ng truyn tnh mch ngn nga tt huyt p do thiu
dch
10. Cc bin php tng o thi c cht l
A. Gy nn v ra d dy
B. Bi niu tch cc
C. Lc mu
D. Thay huyt tng
E. Cc cu B, C v D
11. Trong iu tr ng c cp
A. Thuc gii c l bin php hiu qu nht nu c sn v c dng
sm
B. Tt c mi cht c u c thuc gii c ca n
C. Thuc gii c cho co git do ng c l seduxen, phenobarrbital
D. Dng thuc gii c phi tun th liu ti u c xc nh bi nh
sn xut.
12. Nhm cng vic th 6 l
A. iu tr triu chng.
B. Hi sc ton din
C. iu tr ton din bao gm tip tc cc bin php hi sc - iu tr
triu chng, nui dng, chm sc v gio dc phng chng ti nhim.
D. Khng c cu no ng
128
Bi 16
VN CHUYN BNH NHN CP CU
MC TIU
1. Trnh by c phn loi cc cch di di v vn chuyn bnh nhn.
2. Trnh by c vn chuyn bnh nhn trong bnh vin v chuyn vin.
3.Trnh by c cc t th an ton.
NI DUNG
1. i cng
- vn chuyn bnh nhn t ni ny sang ni khc, nhn vin cu h cn
c mt k hoch r rng. Cn nhm trc trong u chin lc thu nhn v vn
chuyn bnh nhn. Thu nhn l xc nh v tr, che ch v bo v an ton cho
bnh nhn. Trong k hoch nhn vin cu h cn phi bit nhng hn ch ca
mnh cng nh nhng ngun c th huy ng khc v cch tip cn c
nhng ngun . S dng cc trang thit b sn c bt c khi no c th.
- Vn chuyn bnh nhn nng lun c nguy c nht nh do vn chuyn
cho bnh nhn v nhn vin vn chuyn
- Mc tiu ca vn chuyn cp cu:
- C gng hn ch cc nguy c xu do vn chuyn cho bnh nhn
- Trnh chn thng, nguy him cho nhn vin
2. Phn loi
- Di di bnh nhn khi hin trng
- Vn chuyn t hin trng v bnh vin
- Vn chuyn trong bnh vin
- Vn chuyn gia cc bnh vin
3. Nng v di di bnh nhn cp cu ti hin trng
- Kh khn nu bnh nhn b kt ti nhng ch kh tip cn, nguy him
- Cn trnh tn thng cho nhn vin y t (nhn vin y t b thng
hoc t vong s khng cn cu c bnh nhn!)
- Trc khi chuyn i bnh nhn phi c:
129
C t th thch hp
Ph kn, ph m..
m bo an ton
3.1. Khi lp k hoch thu nhn v vn chuyn bnh nhn: cn lu
n 4 yu t sau:
- Tnh trng bnh nhn, bao gm c tnh trng trc mt v nhng nguy
c c th xy ra e do s sng ca bnh nhn.
- S nguy him ca mi trng xung quanh v nhng hn ch khc c
th lm tn thng n s an ton ca bnh nhn v nhn vin cu h.
- Cc phng tin v/ hoc nhng nhn vin cu h sn c ti thi im .
- Sc khe v kh nng cng nh cc hn ch chuyn mn ca nhn
vin cu h tham gia vn chuyn.
3.2. Nguyn tc nng - khing
Khi tin hnh vn chuyn bnh nhn, cn tun theo hai nguyn tc c bn
v nng v khing nh sau:
- Th nht l dng cc nhm c di nht, khe nht vn chuyn bnh
nhn (c nh u, c t u v nhm c mng). Khi c co vi mt tc
trung bnh, hiu sut co c s t ti a. Mt im quan trng l s dng chn
ch khng phi lng nng bnh nhn.
- Th hai l gi cho tay v chn st vi thn ngi trng tm c th
khng b lch. Gi trng lng phi nng gn vi thn mnh. iu ny s
gip nhn vin cu h khng b mt sc khi vn chuyn bnh nhn.
nh gi tnh hnh m bo rng, cc nhn vin cu h c th nng
bnh nhn ln v vt qua bt k tnh hung kh khn no.
Khi nng bnh nhn, c th ca nhn vin cu h s hot ng nh mt
cn trc c kh. thng trng lng ngh ca mt bnh nhn ang cn c
nng ln, cn c mt ch ng hoc mt v tr v mt lc cn thit.
3.3. Hng dn nng - khing an ton
- c lng trng lng phi nng v lng sc mnh. Ch nng trng
lng m mnh c th nng c. Trng lng ti a m mt ngi c th
nng ph thuc vo tui, gii, khi c v hon cnh thc t.
- S dng cc phng tin sn c mt cch hiu qu.
- t c hai chn trn mt t vi mt chn hi t ln trc so vi chn
kia to mt v tr vng chc.
- Phn b trng lng bnh nhn u ln 2 chn.
- Khi phi nng thp di u gi, t ngi ln u gi v i; gi lng
thng. Khng t vo tht lng nng bnh nhn.
130
- Gi vng u. Di chuyn nh nhng. Di chuyn t ngt, xc ny lm c

hot ng qu sc v dn n tn thng c.
- Ln gn bng khi nng bnh nhn v ko v pha hng. Gi cho vai thng
trc vi lng v khung chu.
- Gi thng u gi khi nng m bo i v hng to ra lc nng chnh.
- Chuyn ng thng, trnh xoay, vn. Gi cho vai vung gc vi khung chu.
- i chm, s dng cc ng tc phi hp. Khi vn chuyn bnh nhn hoc
khing cng, bc chn khng nn di hoc rng hn vai.
- Bt c khi no c th, nn i v pha trc, trnh i li to iu kin
thun li cho s cn bng v vic vn chuyn c nh nhng.
- Khi t cng hoc vn khing xung, cn tun th cc nguyn tc nh khi
nng duy tr s an ton.
- Phi hp cht ch v thng xuyn vi cc ng nghip khc trong sut
qu trnh vn chuyn. iu ny s duy tr s phi hp v gip ln nhau
gia cc nhn vin cu h khi gp a hnh khng bng phng hoc nhng tr
ngi khc.
Cn ch ngoi nng bnh nhn nhn vin y t cn phi nng c trng
lng ca cc thit b i km (cng, vng, bnh oxy..)Khi cn la chn, hy
chn thit b sn c nh nht, nh nht hn ch sc lc ca mnh.
3.4. Nng
nng trng lng ln, cn t chn m rng mt cch thoi mi, cng
c bng kha lng trong t th cong vo trong mt cch nh nhng. ng
dng chn cui cng (vng) v t chn vung gc vi mt t. Dn trng
lng c th vo bn chn hoc ngay pha sau. ng ln trong t th kha
lng v nng thn mnh trc khi bt u nng hng ln.
3.5. Hng dn khing an ton
(Trnh mang vc trc tip- c gng dng xe c bnh ln
- c lng trng lng phi nng v lng sc nhn vin
- Phi hp nhp nhng v trao i r rng vi ng nghip
- S dng k thut nng an ton
- t gan bn tay v tt c cc ngn tay tip xc hon ton vi vt c
nng ln. m bo cc ngn tay hng v cng mt gc. t hai tay cch
nhau khong 10. Khi c t bn nhn vin cu h tr ln vn chuyn cng,
mi ngi trong s h ch dng mt bn tay khing cng.
3.6. Hng dn ko - y an ton
- Phi kha lng v trnh xoay vn khi tip cn bnh nhn. Thm vo ,
trnh qu n lng khi vi ln trn cao. Trnh vn qu xa v pha trc trn
15 - 20 bt k vt nng c kch thc kh ln no. Cng nn trnh mi
s gng sc qu mc trn 1 pht
131
- Ko:
+ Nn ko theo hng thng trc vi c th
+ T gi v gi trng lc gn vi c th
- y:
+ Lc y nn pht ra t khong gia vai v tht lng
+ Nu cn y cao: cn chnh li v tr ng ph hp
+ Nu trng lng cn y thp: qu gi v y
3.7. Phn loi di di bnh nhn
- Di di khn cp
- Di di cp cu
- Di di khng cp cu
- Di di mt s nhm bnh nhn c bit
+ Chn thng ct sng, tu
+ Sc
+ C thai..
3.7.1. Di di khn cp:
- Cn di di bnh nhn ngay trc khi thm khm nh gi, chm sc,
n nh tnh trng bnh nhn
- Tnh hung:
+ Hin trng nguy him: m chy, n, cht c ..
+ Khng tin hnh cp cu c do v tr v t th bnh nhn
+ Cn chuyn bnh nhn pha ngoi tip cn bnh nhn nng nguy
kch phia trong
- K thut di di khn cp:
+ Cn trnh lm nng thm cc tn thng (c bit ct sng - tu)
+ Nn ko bnh nhn theo trc dc c th
+ Ba k thut c bn:
. Nm c o - vai o v ko
. t bnh nhn nm trn chn hoc o khoc v ko chn
. Lun tay di nch bnh nhn, nm cng tay bnh nhn v ko t pha
sau
3.7.2. Di di khng cp cu:
- Khi hon cnh hin trng thun li
- Tnh trng bnh nhn n nh
132
- Lp k hoch di di
- Trc khi tin hnh di di bnh nhn, i trng i cu h phi m
bo cc bc sau:
+ C nhn lc cn thit.
+ Cc chng ngi vt c pht hin hoc c di di.
+ Cc trang thit b tt nht sn sng.
+ Cc bc thc hin c tho lun k.
4. Vn chuyn bnh nhn cp cu trong ngoi bnh vin
- Thc t thng xuyn phi vn chuyn bnh nhn nng trong v gia cc bnh
vin v nhu cu chm sc iu tr, hi sc tch cc, thm d chn on..
- Bnh nhn lun c nguy c nng ln v gp nguy him trong khi vn chuyn
- Quyt nh vn chuyn phi thc s c li cho bnh nhn. Lun phi cn
nhc gia ch li v nguy c ca vn chuyn
- Hn ch cc nguy c cho bnh nhn trong qu trnh vn chuyn:
+ Chun b k hoch vn chuyn chu o: nh gi v d on c
nhu cu chm sc v can thip c th phi thc hin trong khi vn chuyn
+ Nhn vin vn chuyn thch hp: x l c cc din bin trong khi
vn chuyn
+ Phng tin vn chuyn thch hp: p ng c cc din bin trong
khi vn chuyn
4.1. Vn chuyn trong trong bnh vin
- Tt nht l vic vn chuyn c m nhim bi i vn chuyn
chuyn nghip
- Chuyn n cc khoa thm d chc nng, chn on hnh nh
- Cc phng can thip
- Phng m
- Khoa iu tr tch cc
4.1.1. Tho lun trc khi chuyn:
- Tho lun gia cc bc s, gia bc s vi y t, gia y t vi y t v
tnh trng bnh nhn, iu tr (duy tr lin tc s chm sc v iu tr bnh
nhn)
- Xc nh ni nhn sn sng n bnh nhn
- Thng bo cho bc s chnh: bnh nhn s chuyn i, ai s chuyn
bnh nhn, cc nguy c c th khi ri khi khoa
- H s bnh n: ghi ch nh vn chuyn, ghi din bin trong qu trnh
vn chuyn
133
4.1.2. Nhn vin vn chuyn:

- Ti thiu phi c hai nhn vin vn chuyn bnh nhn
- Mt y t hi sc cp cu hoc y t chuyn v vn chuyn
- Mt ngi ph: k thut vin, y t thng (bc s)
- C thm 1 bc s trong trng hp nh nhn nhn nng nguy c ri
lon cc chc nng sng hoc nguy c cn can thip
4.1.3. Phng tin:
- My theo di in tim/my ph rung
- Phng tin can thip h hp v bng mt n
- Bnh oxy dng trn 30 pht
- Thuc ti thiu cp cu: adrenalin, atropin, lidocain
- Thuc duy tr: an thn, salbutamol, vn mch
- Tim truyn (my truyn dch, bm tim in)
- Nu th my: my th khi vn chuyn phi m bo cc chc nng
c bn nh my ang th ti khoa hi sc cp cu
4.1.4. Theo di trong khi vn chuyn:
- m bo theo di nh ang c theo di ti khoa hi sc cp cu
- Theo di lin tc v ghi nh k: in tim, nng oxy mu (SpO2)
- Theo di v ghi nh k: HA, mch, nhp th
- Theo di c bit tu theo bnh nhn:EtCO2, o HA lin tc, p lc
ng mch phi lin tc, p lc ni s,plc tnh mch trung tm, cung lng
tim
- Cn c bit lu 2 thi im:
+ Khi ri khoa chuyn: chuyn bnh nhn t ging ln cng
+ Khi n khoa tip nhn: chuyn bnh nhn t cng ln ging
4.2. Vn chuyn gia cc bnh vin:
- Nguy c cao cho bnh nhn trong qu trnh vn chuyn
- Phi cn nhc gia ch li v nguy c ca vn chuyn
4.2.1. L do chnh chuyn bnh nhn gia cc bnh vin:
- Bnh nhn cn c chm sc hi sc tch cc hn
- Cn c k thut thm d chuyn khoa cao hn so vi c s y t ang
iu tr
- Cn c k thut can thip chuyn khoa cao hn so vi c s y t ang
iu tr
134
4.2.2. Tho lun trc khi chuyn

- Bc s vi bc s:
+ Tnh trng bnh nhn, iu tr
+ Xc nh ch nh vn chuyn, chin lc x tr
+ Xc nh ni nhn chun b sn sng n bnh nhn
+ Cch thc v phng tin vn chuyn
+ Chun b phng tin dng c
- H s bnh n:
+ Bnh n tm tt (tnh trng, din bin, iu tr)
+ Tm tt phn theo di, chm sc thc hin iu tr ca y t (duy tr
lin tc theo di, chm sc, iu tr)
+ Cc phim xquang, CT scan, MRI
4.2.3. Nhn vin vn chuyn:
- Ti thiu hai nhn vin (khng k li xe)
- Mt nhn vin l y t hi sc cp cu c kinh nghim, bc s, k
thut vin vn chuyn (lm c: t NKQ, x l lon nhp, cp cu ngng
tun hon, ngng th)
- Nu khng c bc s i cng: cn c phng tin lin lc trn xe v
duy tr lin lc vi bc s
4.2.4. Cc phng tin ti thiu:
- Cc phng tin bo v ng th v duy tr thng kh:
+ Bng v mt n
+ Dng c bo v, khai thng ng th
+ n t NKQ, ng NKQ
+ Bnh oxy dng trn 1 gi
+ My ht m, xng ht m
- My theo di in tim/my ph rung
- Dng c tim truyn tnh mch
- Thuc cp cu, thuc duy tr iu tr
- Phng tin lin lc vi bnh vin chuyn, bnh vin nhn
4.2.5. Theo di trong khi vn chuyn:
- Cc theo di ti thiu
+ Theo di in tim lin tc
+ Theo di nh k: HA- Nhp th
135
+ Nn c: SpO2
- Tu theo bnh nhn:
+ o HA lin tc - ALM phi lin tc - ALNS
+ ALTMTT - cung lng tim
- Nu thng kh nhn to: bo ng ti thiu (AL cao-tut, h ng
th)
- Ghi chp din bin trong khi vn chuyn
4.2.5. Cn c bit lu 2 thi im:
Khi ri khoa chuyn: chuyn bnh nhn t ging ln cng, xe t
Khi n khoa tip nhn:
Khi chuyn bnh nhn t cng sang ging
Bn giao h s bnh n - xquang
Bn giao cc y lnh - thc hin cc y lnh (thuc ang dng, dngthuc pha trong dch truyn..)
m bo s lin tc v theo di - iu tr - k hoch thm d chn on,
iu tr
5. T th bnh nhn trc v trong khi vn chuyn n bnh vin
5.1. T th bnh nhn
- Trc v trong khi vn chuyn l giai on bnh nhn cp cu v
chn thng c nguy c b tin trin nng thm (do rung, lc, ..)
- Cn t t th bnh nhn ph hp vi tnh trng thn kinh, thng kh,
huyt ng, thng tn.
+ Gp phn m bo h hp, huyt ng
+ Hn ch tin trin nng, thng tn thm
+ Lm qu trnh cp cu d thc hin hn
Cn theo di din bin v chn li t th cho ph hp vi tnh trng mi
ca bnh nhn.
- Bnh nhn tnh thng chn cho mnh t th thch hp nht, cm thy
d chu nht.Cn tn trng t th la chn ca bnh nhn nu thy t th y
ph hp
- Trong bnh cnh chn thng:
Lun phi ch n chn thng ct sng, c bit l chn thng ct
sng c
Cn gi thng trc u - c - thn
Np c nu nghi ng chn thng ct sng c
136
5.2. Bn nhm t th c bn
- Nm nga
- Nm nghing
- Ngi
- Nm sp
5.2.1. Nm nga- ngang
Ngng tun hon - ngng th (c n)
Chn thng ct sng: cho php thc hin cc bin php cp cu h
hp- tun hon
5.2.2. Nm nga, chn cao
p dng: chy mu nhiu - gim th tch nng (bnh nhn tnh)
Chng ch nh: gy chn hoc xng chu
5.2.3. Nm nga, i gp
p dng: vt thng hoc chn thng bng kn.
Tc dng: gim au bng (do lm lng cc c bng)
5.2.4. Nm nga, u cao 10-30
p dng: chn thng s no
Tc dng: tng tun hon tnh mch tr v, gim ph no
Nguy c nh hng khng tt ln HA
5.2.5. Nm nghing an ton
p dng: ri lon thc (khng ri lon h hp, tun hon)
Tc dng: Gii phng ng th, hn ch nguy c ht vo phi
5.2.6. T th sn khoa (nm nghing an ton sang tri)
p dng cho bnh nhn mang thai trn 7 thng c tc dng gim chn p
ca t cung vo tnh mch ch di
5.2.7. Ngi - chn thng:
p dng trong trng hp ph phi cp
Tc dng: gim tun hon tnh mch tr v tim
5.2.8. Na ngi - chn thng
p dng: khi kh th v bnh nhn cn tnh (HPQ, bnh phi mn..).
Tc dng: c honh d di ng hn, gim p ca cc tng bng
5.2.9. Na ngi- chn gp
p dng: chn thng bng-ngc.
Tc dng: ngi lm cho th- gp chn lm chng c bng
137
5.2.10. Ngi ng ra trc

Vim np thanh qun (cha t NKQ).
Tc dng: gim cn tr h hp gim nguy c tc ng kh do ph n
np thanh qun. Trong trng hp chy mu mi s lm hn ch chy mu
mi sau
5.2.11. Nm sp
Him p dng, p dng: vt thng hoc vt bng lng qu au
Kh chu cho bnh nhn- nguy c nng thm h hp
Kh theo di bnh nhn
6. Vn chuyn bnh nhn trong bnh cnh chn thng
Cm mu
Vt thng ct ct hoc gn ct ct: gar vng quanh chi
Cc vt thng khc: p trc tip vo ng mch chy mu hoc p
ngay st trn ch vt thng bng bng o HA bm ln trn s HA ti a.
Nu c tn thng xng gy chy mu: nn np bng np hi va cc
tc dng c nh xng va cm mu.
Gy xng v trt khp gy bin dng chi cng cn t li ng t th v
np li trc khi vn chuyn. ng tc x tr ny gip phng cc bin chng:
gy xng kn b chuyn thnh gy xng h, hoi t vng da b cng, ko xon
hoc p ng mch. Bng ph bng bng v khun cho cc gy xng h
T th vn chuyn ty thuc tn thng:
Tn thng chi trn n thun: nn chn t th na ngi (s thoi mi
cho bnh nhn hn)
Tn thng chi di: nn chn t th nm nga, k chn cao khong
10-20 (tc dng gim ph n)
Khng c chi tn thng ri ra ngoi cng, chi ung a khi vn
chuyn
TI LIU THAM KHO
1. S cp cu trong mi trng lao ng, Hi ch thp Vit Nam,
H Ni, 2001
2. Guideline for the transfer of critically ill patients
3. Les dossier du gnraliste
4. Lifting and moving patients. Trong: care and transportation 1997
5. Recommandations concernant les transports
intrahospitaliers. Conference de consensus de la SFAR 1994
138
mdicaliss
CU HI LNG GI
Cu 1: T th ph hp cho mt bnh nhn cp cu v kh th l (1
ng):
A. t bnh nhn t th nm nga u bng.
B. t bnh nhn t th nm nga u thp
C. t bnh nhn t th nm nga u cao
D. t bnh nhn t th nm nghing an ton
E. t bnh nhn t th nm sp
Cu 2. T th ph hp cho mt bnh nhn cp cu v tt huyt p do
mt mu l (1 ng):
A. t bnh nhn t th nm nga u bng.
B. t bnh nhn t th nm nga chn cao
D. t bnh nhn t th nm u cao, nghing an ton
Cu 3. T th ph hp cho mt bnh nhn cp cu nghi ng c chn
thng ct sng l (1 ng):
A. t bnh nhn t th nm nga u bng, trn cng cng.
B. t bnh nhn t th nm nga chn cao
D. t bnh nhn t th nm u cao, nghing an ton
Cu 4. Cc k thut khing cng an ton l (nhiu ng):
A. Trong khi khing cng phi bc chn di v nhanh.
B. Khing cng xung dc hay xung cu thang pha u bnh nhn i
trc.
C. Khing cng ln dc hay ln cu thang pha u bnh nhn i trc.
D. Khing cng xung dc hay xung cu thang pha chn bnh nhn
i trc
E. Theo di bnh nhn trong qu trnh vn chuyn l khng cn thit,
ch cn chuyn bnh nhn tht nhanh.
Cu 5. Cc tiu tr no sau y th hin bnh nhn c vn chuyn
tt (nhiu ng):
A. Cc phng tin dng c, thuc cp cu c chun b y .
139
B. T th bnh nhn trong qu trnh vn chuyn l khng quan trng.

C. Cc chc nng sng ca bnh nhn c theo di cht ch.
D. X tr c kt qu cc bin c xy ra trong qu trnh vn chuyn.
E. Vn chuyn an ton ngi bnh n a im nh v bn giao
y .
140
PHN II
THC HNH
141
THC HNH KIM SOT NG TH

H tn hc vin:
Lp:
Kha hc:
Thi gian:
STT
Cc bc thc hin
thnh
Xc nh nguyn nhn gy tc nghn ng th
t ng t th bnh nhn
K thut nga u nhc cm
K thut n gi hm
K thut Heimlich t th ng (ngi ln + tr

em)
K thut Heimlich t th nm (ngi ln + tr

em)
K thut t canuyn hng ming, mi hng
K thut t mt n thanh qun
142
hon
THC HNH CP CU NGNG TUN HON NNG CAO

H tn hc vin:
Lp:
Kha hc:
Thi gian:
STT
Cc bc thc hin
thnh
Xc nh bnh nhn ngng tun hon
Khi ng dy chuyn cp cu
Chun b
Tin hnh khai thng ng th
Xc nh ng v tr t mask
t mask v bp bng ng k thut
Xc nh v tr di xng c
Cch t tay ng
Tin hnh p tim ngoi lng ngc
10
nh gi hiu qu ca ng tc p tim
11
Hon thnh h s bnh n
143
hon
THC HNH VN CHUYN BNH NHN CP CU
H tn hc vin:
Lp:
Kha hc:
Thi gian:
STT
Cc bc thc hin
thnh
Xc nh nhanh chng tnh trng bnh nhn
Quyt nh phng thc vn chuyn
Thc hnh vn chuyn theo tnh hung
Chuyn bnh nhn nng

Nng bnh nhn
Khing bnh nhn
Chuyn bnh nhn t cng sang ging
Chuyn bnh nhn nh
144
hon
THC HNH
K THUT X L VT THNG XUYN THU
1. Yu cu
- Hc vin nu c nguyn tc x l cc vt thng xuyn thu ti khoa
cp cu
- Tin hnh thnh tho k thut bt ng vt xuyn thu
- Nm c tm quan trng ca vic nh gi v x tr theo cc bc ABC
2. Phng php thc hnh:
- Hc vin va thao tc va m t bng li vi ging vin cc k thut
ang thc hin
- Sau khi hc vin thc hnh xong, ging vin phn tch cc im t v
cha t trong k thut hc vin rt kinh nghim
- Hc vin v gio vin hi p sau thc hnh
3. Phng tin thc hnh:
- Ngi nm: 1
- Bng cun: 10 cm x 5m ( bng chi, ngc)
- Bng cun 5 cm x 2,5m ( bng mt)
4. Cc bc thc hnh
eo phng tin phng h c nhn
C nh ct sng c bng tay
nh gi v kim sot ng th
Ht m di
t canyl ming hu
nh gi v h tr h hp
Oxy liu php
C nh vt xuyn thu ngc nu c
nh gi v h tr tun hon
Bt mch cnh
Mu da
Kim sot chy mu: bng p
eo np c
o kch c np ph hp
145
Khm thng nhanh

Pht hin vt xuyn thu chi c nh
Pht hin vt xuyn thu mt c nh
Chun b cng cng
Nghing bnh nhn
k thut log-roll
kim tra ct sng lng
C nh thn mnh bnh nhn vo cng
C nh u
nh gi mch cm gic vn ng chi
t ng truyn, xt nghim, hi chn
Theo di
146
THC HNH
K THUT C NH XNG GY V CT SNG
1. Yu cu:
- Hc vin tin hnh thnh tho k thut bt ng ct sng c, ct sng
lng v xng chu Hc vin s dng thanh tho cc dng c: np c, np u,
vn cng, ga buc khung chu
- Nm c tm quan trng ca vic nh gi v x tr theo cc bc ABC
2. Phng php thc hnh:
- Hc vin va thao tc va m t bng li vi ging vin cc k thut
ang thc hin
- Sau khi hc vin thc hnh xong, ging vin phn tch cc im t v
cha t trong k thut hc vin rt kinh nghim
- Hc vin v gio vin hi p sau thc hnh
3. Phng tin thc hnh:
- Vn cng km dy buc: Allied HPI XTRA Backboard with Straps
- Np c cng ngi ln: Stifneck Select Collars - Adult
- B c nh u: Head Immobilizer with Straps
- Mt tm toan y t c gp li theo kch thc: 40 x 150 cm
- Panh c mu c nh toan: 6 chic
- Ngi nm: 1
4. Cc bc thc hnh
eo phng tin phng h c nhn
C nh ct sng c bng tay
nh gi v kim sot ng th
Ht m di
t canyl ming hu
nh gi v h tr h hp
Oxy liu php
nh gi v h tr tun hon
Bt mch cnh
Mu da
Kim sot chy mu: bng p
147
eo np c
o kch c np ph hp
Khm thng nhanh
Pht hin khung chu mt vng
Chun b cng cng
Tri tm toan c nh khung chu
Nghing bnh nhn
k thut log-roll
kim tra ct sng lng
Buc tm toan, c nh khung chu
Dng panh c mu cp
C nh thn mnh bnh nhn vo cng
C nh u
nh gi mch cm gic vn ng chi
t ng truyn
Theo di
148

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B Y T

CC QUN L KHM CHA BNH

THAM GIA BIN SON

2. Cc k thut kim sot ng th

3. Chn on v x tr cp cu ban u suy h hp cp

5. Cp cu ngng tun hon c bn

6. Cp cu ngng tun hon nng cao

7. Chn on v x tr cp cu nhi mu c tim cp c ST chnh ln

II. Cp cu chn thng

9. Cp cu chn thng ct sng

10. Cp cu chn thng ngc

11. Cp cu chn thng bng

12. Chn on v x tr cp cu ban u sc chn thng ngi ln

13. X tr cp cu chn thng xng, phn mm v chi th t ri

15. Nguyn tc chn on, x tr ng c cp

16. Vn chuyn bnh nhn cp cu

2. K thut cp cu ngng tun hon

3. K thut vn chuyn bnh nhn

4. K thut x tr vt thng xuyn thu

5. K thut bt ng xng gy v ct sng

than ca bnh nhn, nhn vin) nn d c ln xn, nhiu ting n v kh

3. Cc nguyn tc chnh khi tip nhn v x tr bnh nhn cp cu

-Bc 1 (primary survey): nhn nh v kim sot n nh cc chc nng sng

+ a ra cc chn on bnh l cp cu nguy him, chn on nhiu kh

Cu 1: Cc tiu ch nh gi bnh nhn cp cu l

B. c im hnh thi tn thng

3.1. T th bnh nhn

Hnh 4. K thut nga u nhc cm: (A) Tc nghn ng th do tt li; (B)

* Cc trng hp khc: Bnh nhn suy h hp, ph no, TBMN: t th

Hnh 6. Du hiu kinh in ca d vt ng th

- Nu ch c mt mnh nn nhn: T p bng bng cch n nm tay ln

Hnh 7. Th thut Heimlich khi bnh nhn tnh

Hnh 8. Th thut Heimlich khi bnh nhn hn m

Hnh 10. K thut v lng (A) p ngc (B) tr nh

nh, nu vn kh rt c th do vo vch mi th t l mi bn kia hoc dng

Hnh 12: Canuyn mi-hng: (A) Cc c khc nhau; (B) V tr

Hnh 13. Mt n thanh qun

Hnh 14. V tr mt n thanh qun

Cu 4: Mt BN vo vin v tai nn giao thng c CT s no, v xng

> 40 hoc <

2.3. Chn on nguyn nhn

+ Thiu oxy mu nng km p ng vi th oxy

dng ng kh dung trc, nu khng p ng th chuyn sang truyn tnh

TI LIU THAM KHO

Concepts and Clinical Practice, 6th

3. Kaynar AM: Respiratory Failure. www.Emedicine.com. Cp nht:

1. Trnh by c chn on xc nh tnh trng sc, phn loi sc.

- Sc nhim khun: st, th trng nhim trng nhim c, vim phi, p

4. Cch tip cn bnh nhn sc

- Cc bin php hi sc huyt ng

SVR: sc cn mch h thng

C. Th 14 ln/pht khng phi th oxy qua xng mi hoc mt n.

Cc nguyn nhn gy ngng tun hon thng gp v c th iu tr nhanh

trong ting Vit

Thiu th tch tun

3.3. Cp cu ti Khoa cp cu:

Cu 4: Cch dng Adrenalin trong cp cu NTH (chn 1 ng)

- Cn ghi chp cc thng tin cn thit v tin trnh cp cu.

NTH thng xy ra t ngt, khng d on trc c. Tt c cc nhn

PHC X TR CP CU NNG CAO

Khi ng h thng cp cu ngng tim

Rung tht & nhp nhanh tht vn tn ti hay ti pht ?

(a): Cp bng chng:

Tin hnh ngay tr li BLS x 2 pht