CP NHT CP CU PHN V

TS o Xun C
Khoa Hi sc tch cc BV Bch Mai
 I CNG
Phn ng phn v c th din ra bt c u vi bt
kz loi thuc hoc d nguyn no (thuc hoc ha
cht dng trong chn on v iu tr , thc n, ha
m phm,cn trng t.)
Din bin lm sng phong ph, phc tp , kh lng
trc
cn nhn bit sm cc tnh hung phc tp c th
xy ra ng thi sn sng cp cu kp thi hiu qu
2641 Thi kz 1902 1913
trc CN Babylon Charlet Charlet
Menes cht 2 trng Richat gi c trao
sau khi b hp cht tn hin gii Nobel
ong bp do ong bp tng SC cho nghin
cy t cy t PHN V cu v sc
phn v
Vn khng mi
 Khi t v p ph bnh vin, nh bc s
(Dn tr) - Lin quan n v vic bnh nhn t vong sau khi tim khng
sinh, ngi nh p ph ti bnh vin a khoa H Tnh, C quan iu
tra H Tnh va c quyt nh em v n ra khi t.
Sng 6/9, ng Nguyn Tin Nam, Trng Cng an TP.H Tnh (H Tnh),
cho bit c quan ny va ra quyt nh khi t v n p ph bnh vin,
nh bc s tip tc iu tra v nguyn nhn gy ra ci cht i vi
bnh nhn Nguyn Xun Hng lin quan n bc s o Xun L, Ph
Trng khoa chn thng (ngi a php lnh tim) v iu dng Phan
Vn H (ngi trc tip tim).
Nh Dn tr a tin, trc , ngy 8/8, ng Hng nhp BV a khoa H
Tnh iu tr vi chn on b vim xng. n tra 12/8, cc y, bc s
tim thuc khng sinh Trikazim v Ciprofloxacin Kabi cho ng Hng. ng
Hng t vong do sc phn v. Trc ci cht t ngt ca ng Hng, nhiu
ngi thn c mt ti bnh vin t ra bt bnh, p v mt s my mc,
nh b thng bc s Mai Vn Lc (Trng Khoa Hi sc tch cc) v 3 y,
bc s khc ca khoa ny. Cng an TP.H Tnh phi huy ng hn 40 ngi
mi kim sot c v vic.
p ph bnh vin, nh bc s
 NH NGHA CN PHC TP

Phn ng d ng (allergic reactions)

Phn ng qu mn (hypersentsitivity reactions)
Phn v (anaphylaxis)
Phn ng phn v (anaphylactic reactions)
Phn ng dng phn v (anaphylactoid
reations)
 Nguyn nhn ngy cng nhiu
Foods:Bananas, beets, buckwheat, Chamomile tea, citrus fruits, cows milk,* egg whites,* fish,*
kiwis, mustard, pinto beans, potatoes, rice, seeds and nuts (peanuts, Brazil nuts, almonds,
hazelnuts, pistachios, pine.nuts, cashews, sesame seeds, cottonseeds, sunflower seeds, millet seeds),*
shellfish*
Venoms and saliva: Deer flies, fire ants, Hymenoptera (bees, wasps, yellow jackets, sawflies),*
jellyfish, kissing bug (Triatoma), rattlesnakes
Antibiotics: Amphotericin B (Fungizone), cephalosporins, chloramphenicol ,ciprofloxacin ,
nitrofurantoin (Furadantin), penicillins,* streptomycin, tetracycline, vancomycin (Vancocin)
Aspirin and nonsteroidal anti-inflammatory drugs*
Miscellaneous other medications
Allergy extracts, antilymphocyte and antithymocyte globulins, antitoxins, carboplatin (Paraplatin),
corticotropin (H.P. Acthar), dextran, folic acid, insulin, iron dextran, mannitol (Osmitrol),
methotrexate,methylprednisolone (Depo-Medrol), opiates, parathormone, progesteron
(Progestasert), protamine.sulfate, streptokinase (Streptase), succinylcholine (Anectine), thiopental
(Pentothal), trypsin,chymotrypsin, vaccines
Latex rubber*
Radiographic contrast media*
Blood products
Cryoprecipitate, immune globulin, plasma, whole blood
Seminal fluid
Physical factors
Cold temperatures, exercise
Idiopathic
 C ch qua C ch MD Khng do
C ch
IgE/FcFI khc MD
Cn trng/ong t MD tng hp Gng sc
Nguyn Thc n Hot ha b th Lnh
nhn Thuc Hot ha h ng mu Thuc
Nguyn nhn khc C ch t min Nguyn nhn khc

TB chnh TB mast BC i kim

Histamine Carboxypeptidase A Chymas Leukotriene

Mediator
Tryptase PAF Prostaglandin Khc

C quan
ch
 Yu t tng nguy c hoc tng
mc nng ca phn v

Simons FER, et al. WAO Journal. 2011;4:13-37.

18
HI THO V CP CU PHN V TI CHICAGO 2011
( The journal of emergency Medicine vol 45 no 2,pp 299-306; 2013)

Phn v l mt phn ng nghim trng gy ra

nhiu bnh cnh lm sng khc nhau nhng
c c im chung l xut hin nhanh v c
th dn n t vong
Thng do nguyn nhn phn ng d ng
nhng cng c th khng
 Theo vin quc gia Hoa Kz v D ng v bnh nhim
trng( NIAIP) v H thng theo di d ng thc n v
phn v ( FAAN) M 2005

Xut hin nhanh ( mt vi pht- vi gi )

e da tnh mng ( suy cp tnh cc c quan :
tun hon, h hp, tiu ha)
V vy phi chn on nhanh ( ch yu da vo
lm sng, c chn on phn bit)
v x tr ng v nhanh
 nh ngha ca Anh
L phn ng d ng nng ,ton thn , xut hin
nhanh
e da tnh mng:
H hp : ng th ( ph hng, thanh qun) v
hoc km theo Ri loan v th ( th nhanh, co tht
ph qun) v hoc km theo triu chng ca h
Tun hon : try mch, tt HA
Thng km theo cc triu chng ca da, nim
mc
Thi gian xut hin du hiu phn v u tin
theo Rescusitation Council (UK) 2012
 Da, nim
H hp Tiu ha Tim mch Thn kinh Triu chng
mc khc
Ban , nga, Nga mi, s au bng, nn, au ngc Bt tnh thong Thay i v gic:
my ay, ph mi, chy nc bun nn, kh Mch nhanh, qua, lo lng, kh Cm gic c v
mch, ban dng mi, ni khn. nut, tiu chy nhp chm (t chu ( tr em kim loi trong
si. Nga hng, co i tiu tin xy ra), lon thng biu ming
Nga, , ph tht thanh qun, khng t ch nhp, hi hp hin: d b kch au qun, ra
n xung quanh ni kh, th kh nh trng thch, ngng mu m o do
mt, xung huyt kh, ho khan ngc. chi, bm cha co bp t cung
kt mc, chy tng cn. H huyt p, m). ph n
nc mt. Tm ti ngt au u, thay
Nga mi, li, Suy h hp Suy tun hon i nhn thc,
vm ming v hoa mt, chng
vnh tai, sng mt, ln ln,
mi, li gim th lc
Nga b phn
sinh dc ngoi,
gan bn tay, gan
bn chn
 TI SAO T VONG
Chn on v x tr chm
C quan no b nh hng dn n t vong ?
1.H hp : do tc nghn ng th ( Airway:
ph ming,li,hng, h hng, thanh qun)
khng th c ( Breathing) do co tht ph qun
2. Tun hon : gin mch nng, thot qun,
co mch vnh, thiu mu c tim
 Ph c th ti ch hoc ton
thn , din bin kh lng , nguy
him nht l ph li,hng,thanh
qun

bbba
 HIN TNG TNG TNH THM MAO MCH
( mt 35% nc trong lng mch trong vng 10 pht)
Vy phi lm g ?

Th gii ?
Vit nam ?
Mi c s ?
 Th gii
nh ngha n gin , nhn mnh triu chng
lm sng d nhn bit
Phn loi chn on v x tr sm
Ph bin rng ra cng ng t cp cu trc
khi nhn vin y t c mt
 Chn on phn bit
Triu chng Chn on phn bit
(Am Fam Physician 2003;68;1325-32)

Tt Huyt p Sc nhim khun

Phn ng cng ph giao cm
Sc tim
Sc gim th tch
Suy h hp km theo c ting D vt thanh qun, Hen ph qun, t cp COPD
kh kh hoc ting rt Hi chng mt chc nng dy thanh

Try mch sau ba n D vt ng th

Ng c Monosodium glutamate
Ng c Sulfite
Ng c c Scombroid
Hi chng chng mt Carcinoid
Sau mn kinh (cn nng bng mt)
Hi chng da (vancomycin *Vancocin+)
Khc Ngt do qu s hi
mastocytosis h thng
Bnh ph mch di truyn
Bnh leucemia c km tng sx histamin
 Phc x tr phn v lin quan n thc n
( Journal of pediatric Health care vol 27 number 2s)

Khi C bt k 1 hoc nhiu triu chng nng 1. TIM EPINEPHRINE

sau : NGAY LP TC
PHI: th nng, kh kh, ho nhiu 2. Call 911 ( gi cp cu )
TIM: tm ti, mch yu, chng mt,ln ln 3. Bt u theo di
HNG : cm gic chn hng, khn ting, ri 4. Thm thuc :
lon nut hoc th -Antihistamine
MiNG: ph to ( li hoc mi) -Ht cc thuc gin ph qun nu hen
cn tr nut ,th
-Vn phi sdng EPINEPHRINE
DA : ban nhiu ni hoc kt hp vi cc triu
chng trong cc trng hp nng mc d
Ban, sn nga, ph ( mt, mi) dng khng Histamin v thuc
RUT; au qun bng, nn , a chy gin ph qun

CH C TRIU CHNG NH: 1. DNG ANTIHISTAMINE

MiNG: nga 2. theo di, bo cho nhn vien y t v gia nh
DA: mt vi ban quanh ming 3. Nu triu chng tin trin nng nh trn,
hoc mt, nga t phi DNG EPINEPHRINE
RUT: y bng hoc bun nn t 4. Bt u theo di ( sc mt, kh th, ..)
 Triu chng v phn loi phn ng qu mn ( M)

Mc Cc triu chng
1.Nh (ch c da v t da nhiu, sn nga hoc ph quanh mt ho
chc di da ) ph mch,

2. Trung bnh (bt u c Kh th, th kh kh, th rt, bun nn, nn, chng
du hiu ng h mt , mt xu (trc khi ngt ),
hp, tim mch hoc tiu Nhn i, chn ngc , hoc au bng
ha )

3 .Nng (thiu oxy, tt HA Xanh tm hoc SpO2 92% at any stage, tt huyt p
hoc du hiu thn kinh) (SBP < 90 mmHg ngi ln), ln ln, try mch ,
mt thc hoc i khng t ch

Brown SGA. Clinical features and severity grading of

anaphylaxis. J Allergy Clin Immunol; 114:371376. Copyright
(2004),
 Hi Gy m Hi sc Php
Prise en charge dun choc anaphylactique
www.sfar.org 2010

Triu chng lm sng

GRADE I du hiu da, nim mc ni chung.
GRADE II nh hng n chc nng tng (t nht 2 tng )
GRADE III nh hng chc nng nhiu tng nng e da tnh mng
v cn iu tr chuyn bit
GRADE IV Ngng tun hon/hoc h hp
Cc du hiu da c th khng c hoc ch xut hin sau khi huyt p tng tr li

iu tr
Gi ngi gip , ngng tim truyn cc cht nghi gy phn v
Hi chn ni -ngoi khoa ( cn trnh lm gi?, n gin ha, phu thut khn
trng ho ngng phu thut )
Oxy liu cao v kim tra nhanh ng th
ng truyn tnh mch m bo
Bi ph th tch : dch tinh th ng trng (30 mLkg-1) sau amidons (30
mLkg-1)
ADRENALINE IV iu chnh liu mi 1 2 pht, ty theo mc nng ca phn v
 Hi Gy m Hi sc Php
Prise en charge dun choc anaphylactique
www.sfar.org 2010

nhp nhanh khng phi l chng ch nh dng adrenalin

Grade I : khng dng adrnaline
Grade II : bolus de 10 20 g
Grade III : bolus de 100 200 g
Grade IV : cp cu ngng tun hon
- MCE : massage cardiaque externe ( p tim ngoi lng ngc)
- BOLUS 1 mg dADRENALINE mi 1 2 pht sau 5 mg t ln th ba
Liu adrenalin phi tng ln , sau truyn lin tc liu 0,05 - 0,1
gkg/pht

NHN XT
C cn chia 4 mc khng ?
Nn gp Grade II v III lm mt
Khi c nhp nhanh khng c tng huyt p : tim bp
Nu c km theo tng huyt p : truyn tnh mch iu chnh theo mc
suy h hp v try mch
 VIT NAM
LN 1 : LU
Chn on khi c sc ( tt huyt p)
Adrenalin dng d dt : tim di da 1mg
sau trng x ranh tim tnh mch
Ln 2 : phc 1999
(Thng t s 08/1999-TT-BYT ngy 04 thng 05 nm 1999)
 PH LC 6
PHC CP CU SC PHN V
TRIU CHNG
Ngay sau khi tip sc vi d nguyn hoc mun hn, xut hin:
- Cm gic khc thng (bn chn, ht hong, s hi... ), tip
xut hin triu chng mt hoc nhiu c quan:
- Mn nga, ban , my ay, ph Quincke
- Mch nhanh nh kh bt, huyt p tt c khi khng o c
- Kh th (kiu hen, thanh qun), nght th
- au qun bng, a i khng t ch
- au u, chng mt, i khi hn m
- Chong vng, vt v, giy gia, co git.
 PH LC 5
NI DUNG HP THUC CP CU CHNG SC PHN V
(Km theo Thng t s 08/1999-TT-BYT ngy 04 thng 05 nm 1999)
A. Cc khon cn thit phi c trong hp thuc cp cu sc phn v (tng cng: 7
khon)
1. Adrenaline 1 mg - 1 ml 2 ng
2. Nc ct 10 ml 2 ng
3. Bm kim tim v khun(dng mt ln): 10 ml 2 ci .1 ml 2 ci
4. Hydrocortisone hemisuccinate 100 mg hoc methyprednisolone
(Solumedrol 40 mg hoc Depersolone 30 mg) 2 ng
5. Phng tin kh trng (bng, bng, gc, cn)
6. Dy ga-r
7. Phc cp cu sc phn v
B. Tuz theo iu kin trang thit b y t v trnh chuyn mn k thut ca tng tuyn, cc
phng iu tr nn c cc thit b y t sau:
- Bm xt salbutamol hoc terbutaline
- Bng Ambu v mt n
- ng ni kh qun
- Than hot
 Th test v gi tr ca th test ?
6. V vic lm test (th phn ng)
a. Trc khi tim penicillin, streptomycin phi lm
test cho ngi bnh.
b. K thut lm test
Lm test ly da hoc lm test trong da, khuyn khch
lm test ly da v d lm.
Vic lm test phi theo ng quy nh k thut (theo
quy nh ti ph lc s 4)
c. Khi lm test phi c sn cc phng tin cp cu
sc phn v
 II. X TR:
A. X tr ngay ti ch:
1. Ngng ngay ng tip xc vi d nguyn (thuc ang dng tim,
ung, bi, nh mt, mi)
2. Cho bnh nhn nm ti ch
3.Thuc: Adrenaline l thuc c bn chng sc phn v
Adrenaline dung dch 1/1.000, ng 1ml = 1mg, tim di da ngay
sau khi xut hin sc phn v vi liu nh sau:
+ 1/2 - 1 ng ngi ln
+ Khng qu 0,3 ml tr em (ng 1 ml (1mg) + 9ml nc ct = 10
ml sau tim 0,1 ml/kg)
+ Hoc adrenaline 0,01 mg/kg cho c tr em ln ngi ln.
Tip tc tim adrenaline liu nh trn 10 - 15 pht/ln cho n khi
huyt p tr li bnh thng.
Tim di da hay tim bp? Nhc li sau mi 10-15 pht c chm
qu khng ?
 Mt s nhn xt
Nn sp xp li.ch cn thy du hiu da hoc nim mc km 1 trong cc
du hiu e da tnh mng :
A :Airway : + ph li, hng, nut kh
+khn ting hoc th kh kh
B: Breathing: + kh th nhanh,
+ c ting rt, mt
+ sPo2 < 92%
+ ln ln, vt v do thiu oxy, xanh tm
+ ngng th
C: Circulation: + mch nhanh, yu
+ da lnh hoc du hiu thiu oxy no ( vt v )
+ try mch ,tt huyt p
+ ngng tim
D. hoc c quan tiu ha : bun nn, au bng, nn, a chy
 Mt s nhn xt
Nn phn mc nng c hng x tr thch hp,
Nn phn 3 mc : Nh . Nng , v Nguy kch cho d nh , v iu tr
sm
Nh : ch c du hiu da hoc nim mc khng c suy chc nng bt c
tng no
Nng : l khi c du hiu bt c tng no
A :Airway : ph li, hng, nut kh hoc khn ting , th kh kh
B: Breathing: kh th nhanh, th c ting rt, mt sPO2 < 92%. ln ln,
vt v do thiu oxy, xanh tm, ngng th
C: Circulation: mch nhanh, yu da lnh hoc du hiu thiu oxy no ( vt
v ) try mch ,tt huyt p , ngng tim
D. hoc c quan tiu ha : bun nn, au bng, nn, a chy
Cc mc khng c nh ,c th chuyn bin nhanh
Nguy kch: du hiu thiu oxy nng (chn ngc, mch nhanh hoc chm ,
HA cao , hoc thp <90 mmHg, th nhanh hoc ngt th , SpO2<92% ,
hoc c hn m
 Mt s nhn xt
Th test gi tr n u ( th gii khng lm )
K thut th v kt qu tin cy mc no ?
Nu m tnh d lm cho ngi ta l l cnh gic,khng chun
b sn sng c v tinh thn v dng c cp cu
NI DUNG HP THUC CP CU CHNG SC PHN V Chun b hp
chng sc vi 2 ng adrenalin l t qu
Khng cho phc cp cu vo hp chng sc ( treo trn
tng hoc phi c tp hun thnh tho )
X tr : adrenalin nn tim bp , khong cch tim l 5 pht
hoc ngn hn ty theo p ng ca bnh nhn ( 10-15 pht
lu qu )
Ai l ngi cp cu ban u?
Bc s hay iu dng ?

Bc s u ?
Dng c , thuc ,oxy sn sng
S Phn loi mc nng ca khoa HSTC Bch Mai
 Kt qu cp cu phn v p dng
theo phc khoa HSTC ti mt s
bnh vin
 Phn b s liu trong nghin cu

Gm 161 BN. Trong 154 BN p dng PHC v c 7 BN

(chim 4.3%) khng p dng theo phc
 Kt qu iu tr

154 BN iu tr theo phc , khng c t vong.

63 BN (40.9%) ht phn ng d ng, khng xut hin nng thnh phn v.
91 bnh nhn (59.1%) phn v khi
7 BN khng theo phc , trong c 5/7 trng hp (71.4%) t vng
 Phn b theo la tui v gii tnh
Nhm iu tr theo phc

Nhm theo phc : 154

Tui trung bnh 41.5 18.4,
BN, 7nam v 79 n. T l
t 3 thng - 89 tui.
nam/ n l 1/1
C 2.6% di 12 tui (t s liu bnh
vin Hng Vng)
 Tin s v nguyn nhn d ng

151/153 bnh nhn khai thc c tin Trong nhm c tin s d ng:
s d ng ch c 14.9% bnh nhn phn - D ng thuc (63.8%)
v c tin s d ng t trc. -D ng thc n 27.3%
 Nguyn nhn gy phn v ti BV Khoa HSTC
Bch Mai

Trong s 70 BN phn v ti Khoa HSTC BM

- Do ch phm mu 48BN (66.8%)
- Do khng sinh 18 BN (25.7%)
 Mc phn v phn loi theo phc khoa
HSTC Bch Mai

- Ti Bch Mai: 70 BN, mc nh chim t l cao nht

Trong 154 bnh nhn,: (61.4%), do pht hin v iu tr sm
- Mc nh: 66 bnh nhn - Cc BV tnh: c 21bnh nhn, trong mc nh ch
(42.9%) chim 19% v mc nguy kch ln n 42.9%.
- Nng: 52 BN (33.8%) BV nh: c 63 bnh nhn, nhm nh 30.2% v nhm
- Nguy kch: 36 BN (23.4%) nguy kch ch chim 25.4% (do c pht hin v x tr
kp thi), trong c 50 BN (79.4%) c dng adrenalin
v ch 20.6% khng phi dng n adrenalin.
 Din bin lm sng phn v

Phn v xy ra ngay tc th: 6BN (chim 3.3%)

Nhm t 2 20 pht chim t l cao nht (34.2%)
 Nhn vin y t u pht hin phn v

-Ti ICU Bch Mai: 68/70 (97.1%) pht hin ban u bi iu dng
- Ti BV Hng Vng: c 29/32 (90.3%) do iu dng v c x tr ngay lp tc
bng cch tim ng adrenalin
- Ti BV QT Hi Phng: 10/11 (91%) pht hin ngay bi iu dng
 Cc triu chng lm sng ca phn v

77%c triu chng da v nim mc. 52.6% c Kh th v th rt khng c

th t xut hin , BN c th c 1-2 hoc 3 triu chng
 Triu chng lm sng ca phn v

Tng HA: 16 BN (10,6%), HA tm thu cao nht 250 mmHg

Tt huyt p: 40 BN (26.5%)
Ngay khi pht hin phn v, huyt p trung bnh 97 33 mmHg
Tnh hnh s dng adrenalin trong phn v
 Tnh trng s dng adrenalin
S dng adrenalin Tng
Adrenalin C khng
Mc n % n %
Nh 13 13.3 53 94.6 66
Nng 49 50.0 3 5.4 52
Nguy kch 36 36.7 0 0 36
Tng 98 100 56 100 154

98 BN c s dng adrenalin, .
66 BN nh, c 13 BN (19.6%) c s dng adrenalin
56BN khng c s dng adrenalin, c 3 BN(5.4%) mc nng.
 Tnh hnh s dng adrenalin cc BV

Adrenalin BVBM BV tnh BV t nhn nh Tng

Mc n = 27 % n = 21 % n = 50 %

Nh 1 3.7 4 19.0 8 16.9

Nng 15 55.6 8 38.1 26 52.0
Nguy kch 11 40.7 9 42.9 16 32.0
Tng 27 21 50

bnh vin Bch Mai, bnh nhn c pht hin v x l kp thi ngay t u nn s lng
bnh nhn c s dng adrenalin t hn, ch nh adrenalin cho nhm nh t hn.
 Cch s dng adrenalin

Ngay ban u, 95.9% adrenalin c tim tp, khng c trng hp

no tim di da.
 Liu adrenalin trong phn v

Liu adrenalim Trung bnh Nh nht Ln nht

Khi u ( n= 98) 0.64 0.23 mg 0.3 1.0 mg

Lp li ( n = 23) 0.99 0.56 mg 0.3 2.0 mg

Duy tr ( n = 46) 0.20 0.29 mcg 0.05 1.5 mcg/kg/pht

98 BN dng adrenalin khi u ( - 1 mg )

23/98 phi dng liu lp li
46/98 ( chim 46.9%) ch cn phi truyn TM duy tr adrenalin 1-2
ngy
 Din bin lm sng sau tim adrenalin

c 21 bnh nhn khng kp o mch, huyt p khi phn v

Sau phn v 15 60 pht nhp tim ca cc BN , nhanh nht l 195 ck/p.
Sau iu tr khong 2h, nhp tim ca bnh nhn n nh.100-120 /pht
 Din bin lm sng sau tim adrenalin

C 21 bnh nhn khng o mch, huyt p trc khi xy ra phn v.

Ngay khi bt u phn v c bnh nhn tng huyt p, cao nht ln 250 mmHg
Sau khi c tim adrenalin huyt p c xu hng n nh dn sau 1 h
Din bin lm sng sau tim adrenalin
 Kt qu iu tr

Nhm bnh nhn iu tr theo phc c

154 bnh nhn:
- 63 BN (40.9%) ht phn ng d ng, khng Nhm khng theo phc :
xut hin nng thnh phn v. -5/7 BN (71.4%) phn hin, x tr
- 91 bnh nhn (59.1%) phn v khi
mun nn t vng.
- T vong: 0%
- 13 BN(19.6%) trong nhm nh c dng -2 trng hp phn v ko di dn
adrenalin khng gy bin chng: nhp nhanh, au n suy a tng
u, tc ngc
Trn trng cm n !