The Washington Manual ORG redkenTHU CUA GIAO su’ MARIN KOLLEF GUI DOC GIA VIET NAM Chuyén ngénh Hoi site - Cap cttw la mot link vec nghién ctru va the hank dang ngay mét direc quan tém tai Viét Nam. Téi rdt vink hanh khi duoc biét cudn sdch “The Washington Manual of Critical Care Medicine” dugc chuyén ngit sang tiéng Viét. Téi hy vong cuén sdch nay sé tro gitip hitu higu cho cae thay thude Viét Nam qua vige cung edp cho ho céc quan diém cham séc tién tién cho bénh nhan hoi ste cdp cttu. - Marin Kollef - Thét la m6t niém vui lon adi voi t6i khi duoc biét cud tiép can theo céc phic di “Héi site cép ctu Gn ban lan thit 2 ngay sau khi xudt ban tai My da nhanh chéng duoc chuyén ngie sang tiéng Viét. Chuyén nganh Héi site - Cép cttw & Viet Nam dang ngay m6t phat trién rong khap vé cé sé legng bénh nhan duoc tich cue cing nlue chat luong téng thé cita dich vu Héi site - Cap citu doi voi ngudi benh. ste Téi hy vong la cuén sdch “Héi site cp citu tiép cin theo cde phac di ban lan thit 2 cé thé cung edp cée kién thite déo tgo cho ctic thdy thuéc Héi site - Cap cttw Viét Nam vai muc dich gitip cai thién tién luegng cho cdc bénh nhdn bi bénh nang can héi site. - Marin Kollef, MD - Professor of Medicine Washington University School of MedicineLOI GIO! THIEU CUA GIAO SU V0 VAN DINH Cuén sich “The Washington Mannual of Critical Care Medicine” tdi ban Jan thit 2 (nam 2012) do cdc Gido sw Marin Kollef va Warren Isakow lam chit bién Ja mot eudn stich 6 gid tri, mang tinh chat hign dai, edp nhat va tec tién ctta bn sich giéo khoa vé Hoi site chuyén nganh Héi site cdp cttw Hoa Kj va la mot cuon sai Cép citu ciia truéng Dai hoe Washington ma cde bde st chuyén khoa Hoi site Cap cite Vigt Nam luén dénh gid cao Ban bién dich do PGS.TS. Nguyén Dat Anh va PGS TS. Pang Quéc Tudn lam chii bién da khing ngai cde khé khan vé tit ngie va théi gian bién dich sang tiéng Viet dé cdc bac si Viet Nam c6 co héi mau chong tiép dé chan dodn var xie tri dé hiéw cén nhiing kién thite moi nkdt thong qua cae phdc bang tiéng Vigt. Téi hoan nghénh va danh gid cao cdc né le etia Ban bién dich va xin tran trong gidi thigu ban dich tiéng Viet tie nguyén ban “The Washington Manual of Critical Care Medicine” dueéi tua dé: “Héi site edp citu tiép can theo cde phac a8” voi cae ban ding nghiép lam céng tae Hoi site Cap citu va céc ding nghiép chuyén khoa lam sang khde, Ha Noi, ngay 08 thing 8 ndim 2012 Chi tich Héi HSCC va CD Viet Nam Chuyén gia cao cap B6 y té GS. Vi Van DinhMUC LUC Loi gidi thigu Cae tic tiéng Viet viet tat trong sch TINH TRANG SEPSIS NANG VA ul OC NHIEM KHUAN SOC CAN NGUYEN TIM 19 SOC PHAN VE 33 CAC NGUYEN NHAN CO GI6I GAY SOC 39 ee TIEP CAN BENH NHAN SUY HO HAP 59 CAI DAT BAN DAU CAC THONG SO MAY THO 67 TAC NGHEN DUONG HO HAP TREN 15 fai) | TON THUONG PHOI CAP VA HOI CHUNG SUY 85 HO HAP CAP TIEN TRIEN TINH TRANG CON HEN PHE QUAN NANG 99 DOT TIEN TRIEN CAP CUA BENH PHOI TAC ww NGHEN MAN TiNHROI LOAN NHIP THO LIEN QUAN YOI GIAC NGU 6 BENH NHAN HOI SUC CAP CUU TANG AP MACH PHOI VA SUY THAT PHAL GS BENH NHAN HOI SUC CAP CUU TAC MACH PHOL CAC BENH LY MANG PHOI GAP 6 BENH NHAN HOI SUC CAP CUU CAI THO MAY Ubi) THONG KHi KHONG XAM NHAP AP LUC DUONG NHOI MAU CO TIM CAP ROI LOAN NHIP TIM VA CAC BAT THUONG DAN TRUYEN BOC TACH DONG MACH CHU SUY TIM MAT BU CAP TIEP CAN CAC TINH TRANG TANG HUYET AP CAC ROI LOAN TOAN-KIEM NGUON GOc CHUYEN HOA CAC ROI LOAN TOAN-KIEM DO HO HAP 121 129 143, 183 207 233 245 257 CAC BAT THUONG BIEN GIAL 269 323 343(ed cic BENH LY TUYEN GIAP inary) | SUY THUONG THAN O BENH NHAN 357 HOT SUC CAP CUU inis-4) | DAI THAO DUONG CO NHIEM TOAN XETON 367 VA TINH TRANG TANG DUONG HUYET TANG AP LUC THAM THAU MAU KIEM SOAT DUONG HUYET TAL 377 KHOA HOI SUc CAP CUU CAC CAP CUU VE BENH LY UNG THU’ CAC TINH TRANG ROI LOAN, THAN NHIET NHIEM TRUNG HE THAN KINH TRUNG UONG ViiM PHOI MAC PHAI TU CONG DONG 467 VIEM PHO! BENH VIEN 473 viéM MO TE BAO! VIEM CAN CO/ VIEM CO 485 (| CO VI KHUAN TRONG MAU VA NHIEM KHUAN 495 THEO DONG MAU LIEN QUAN VOI CATHETER NHIEM TRUNG XAM LAN DO NAM 503xxiv iiwaye A | NHIEM TRUNG 6 BENH NUAN BI 515 SUY GIAM MIEN DICH Celttuis DY PHONG NHIEM TRUNG TAT CAC KHOA 533 HOI SUC CAP CUU CLOSTRIDIUM DIFFICILE VA CAC NGUYEN S4l NHAN NHIEM TRUNG KHAC GAY iA CHAY TON THUONG THAN CAP DIEU TRI THAY THE THAN (Clitisnjacs) | SUY GAN CAP NANG TANG BILIRUBIN MAU 615 BENH GAN GIAI DOAN CUOI 621 pert GAG ROILOAN CUA DA DAY -RUOT (HE TIEU HOA) CHAY MAU DUONG TIEU HOA TREN 631 oe, CHAY MAU DUONG TIEU HOA THAP 649 VIEM TYY CAP ROT LOANIGHUC NANG THAN KINH. TRANG THAI DONG KINH DOT QUY THIEU MAU NAO CUC BQ CAP 689 Chuo CHAY MAU DUOI NHEN DO 697 TUI PHINH DONG MACH CHAY MAU NOISQ. Chir m1HON ME CAC BENH LY TOY SONG CAP TiNH BENH LY THAN KI I INH CO 6 BENH NHAN HOI SUC CAP COU \) | TON THUONG NAO Do CHAN THUONG VA TANG AP LUC NOI so nenra! | TEP CAN THAN KINH HQC DOI VOI. CAC NHIEM TRUNG HE THAN KINH TRUNG UONG fens GIAM TIEU CAU 6 BENH NHAN HOI SUC CAP CUU XU’ TRI CAP CU'U BENH NHAN BI CHAY MAU/ROI LOAN DONG MAU THYC HANH TRUYEN MAU TINH TRANG TANG DONG CHAM SOC BENH NHAN CHAN THUONG TAIL KHOA HOI SUC TICH CYC TINH TRANG BUNG CAP 757 7 779 789 799 829 879 895axxvi Chirong 70 obs Bile ow Chirong 81 XU TRI NGUOI HIEN TANG DINH DUGNG CHO BENH NHAN HOI SUC CAP COU DAT CATHETER DONG MACH DAT CATHETER TINH MACH TRUNG TAM DAT NOI KHi QUAN MO KHi QUAN QUA DA MO MANG PHOI DAT XONG DAN LUU. CHQC DICH 0 BUNG CHQC DICH NAO TUY CHOC DICH MANG PHOI DAT CATHETER DONG MACH PHOI CAC KY THUAT THEO DOI HUYET DONG THAY THE THEO DOI CHUC NANG HUYET DQNG CHQC DICH MANG TIM XX CAC GIAT PHAP CHAM SOC BENH NHAN TAT DOAN CUO] CHAM SOC BENH NHAN BI BENH GIAI DOAN CUOI TAI KHOA HOI SUC CAP CUU 907 933 941 951 961 967 975 979 987 993 1003 1015 1025 1033citi | CAC PHUONG TRINH VA CONG THUC TINH 1044 TOAN THUONG DUNG TAI KHOA HOLSUC cAP cUU CAC TUONG TAC THUOC 1051 LIEU THUOC THUONG DUNG VA CAC TAC 1057 DUNG PHY.Chuong 1 DAI CUONG VE SOC (Introduction to Shock) Marin H. Kollef 6c la mot van a8 thudng gap tai ce khoa HSC, tinh trang nay ddi héi phai due chan doan va didu tri ngay. Séc thuong due xac nhan dya trén vigc két hop cac théng sé huyét déng (HA trung binh < 60 mmHg, HA tam thu < 90 mmHg) voi céc dau hiéu lam sang (r6i loan y thie, gidm thé tich nude tiéu) va cdc xét nghiém bat thuéng (tang ndng dé lactat mau, toan chuyén héa). Buse tiép can dau tién déi véi tinh trang séc la phat hién dugc nguyén nhan gay séc, do mdi nguyén nhan khac biét sé cdn cdc bién phap can thigp khac nhau. Bich diéu tri chung la phyc hai lai cng nhanh cang tét tinh trang giam tuéi mau mé 48 bo tdn chive nang cdc co quan. Bang 1.1 va Phéc dé 1.1 va 1.2 trinh bay cdch tiép cn a8 xdc dinh nguyén nhan chinh gay séc.Raa se wa ee 2 | wOrsUC CAP CUU - Tidp can theo cic phac dé (© fai (ANE inpatient pe “(eceeiaue LOM SOC CL SYR PVR SVO; RAP RVP PAP PAOP Sée do tim (Vd. NMCT hofe tran dich mang tim gay ép tim cap) Séc gidm thé tich (Vd: séc mat mau, thiéu hut thé tich trong long mach) ca Séc do réi loan phin bé (distributive shock) (Vd: sdc nhiém khuan, sée phan vé) at ot Loot dy de 4b Lt Séc do tic nghén (Obstructive) (Vdtic J Lt t Lt ft t tee mach phéi) Cée tic tiéng Anh vide tit CT (cardiac index) Chi s6 tim; SVR (systemic vascular resistance): Site ein mach hé théng; PVR (Pulmonary vascular resistance): Stte cin mach phdi; SVOs (mixed venous oxygen saturation): BG bio hoa oxy mau tinh mach tron; RAP (right arterial pressure): Ap lye ahi phir; RVP (right ventricular pressure): dp Ive thit phai; PAP (pulmonary artery pressurre): Ap lve dong mach phi, PAOP (pulmonary artery occlusion pressure): ap Iytc dng mach phar bit; fe Tang, | Gidm; L. Binh thyang, "91 C6 tinh trang ding ap (equalization) ea ca ép lye nhi phai (RAP), dp Ie déng mach phoi bit (PAOP), 4p luc dong mach phor (PAP) thi tim chwong va dp lye thét phai (RVP) thi tim chyong chi dan ¢6 ép tim cip do tran dich mang ngoai imChwong 1: Dai cwong vé sbc Bénh canh lam sing séc HA tim thu < 90 mmHg MAP <60 mmHg NGng dé lactat mau > 4 mmol/L. Cung lugng tim bj giam CI<2,2 L/min/m* (khi durge do bing phuong phap hda loang nhiét hay danh gid dang song dong mach chi bing doppler qua thre quan) Co Khong Séc giam thé tich S6c nhiém khudn Ap lure mach nay (Pulse pressure) 4 4 1 HA tam tong l 1 UW Dau chi (Extremities) Lanh Lanh Am Tinh trang héng tré lai sau khi 4n nén méng tay (Nailbed blood Cham Cham Nhanh return) Ap luc tinh mach canh (Jugular 1 1 1 venous pressure) Ral 4m (hay nd) & phéi +H - - Nhip nguaa phi $3, Sy +H - - Phim X-quang ngye Béng tim to, Kich thude tim Binh thuéng, hii phdi bigidm ai Kh cé viem Ri J phi Phét hign dugc 6 nhiém tring - - +H Cie i tiéng Anh vide it: MAP (mean arterial pressure): huyét ip dng mach trung binh; Cl (cardiac index): Chi s6 tim, XW tri cy thé déi voi ting loai séc sé duge a8 cap trong cdc chuong ké tiép. Banh gié som BN bang siéu am tim, danh gia dang song déng mach4 | WOLSUC CAP CUU - Tiép efin theo cdc phic db chi qua thye quan (intraesophageal aortic waveform assessment) hay dat catheter d6ng mach phdi (théng tim phai) sé giup xdc dinh nguyén nhan gay séc va hé trg cho diéu tr séc. Danh gid cung lugng ti bing phuong au hda loding nhi¢t (thermoditution) hay dinh gid dang song dng mgch chia (aortic _ waveform assessment) bing Doppler qua thye quan Cung lugng tim cao (Cl>35- 4.0 Limin/m?) | | Xem xét chin doan Ap he ni phi tir thap dén binh thuong va BN | | | + Bénh Paget * Con bio giip | khéng dap img vor * Dj dang déng- tinh | truyén dich By | az =| |Xem [em xét chin doin | * Shock do t6n thurong tay (spinal shock) © Séc phan ve * Suy thugng thin Cade tie tiéng Anh vier tit. Cl (Cardiac Index): Chi sd tim. Cung Iugng tim tir thip dén binh throng (CI = 2,2 - 3,5 L/min/m?) Ap lye nhi phai cao va BN dap ting vai truyén dich Xem xét chin doin ‘* Tic mach phdi * Trin dich ming tim gay ép tim cap * NMCT tht phaiChuong 2 SOC GIAM THE TicH (Hypovolemic Shock) Marin H. Kollef S 6c gidm thé tich 1a hau qua cua tinh trang gidm thé tich mau Ivu hanh, voi nguyén nhan thong gap nhat la do chay mau cp. Tinh trang nay cling cé thé do thiéu hut thé tich trong long mach do nhiét do cao (heat-related intravascular volume depletion) hodc do tich dong dich (fluid sequestration) trong 6 bung gay nén. Bang 2.1 trinh bay phan loai séc gidm thé tich dua theo téng thé tich mau toan phan bi mat. Noi chung, khi lvong mau toan phan bi mat cang nhiéu, nguy co’ tir vong lién quan voi mat mau cang cao. Tuy nhién, mét sé yéu té khac cling co thé anh hung toi két cuc cia séc gidm thé tich nhu tudi, bénh ly ndi khoa di kém (Vd: bénh ly tim mach) va mirc 46 khan trvong va hdi strc truyén dich théa dang cho BN. Nhiém toan lactic x4y ra trong séc gidm thé tich do hau qua cia giam tudi mau m6. Mire 46 tang ndng dé lactat mau co tong quan voi ty 1é tur vong trong séc gidm thé tich va co thé str dung théng sé nay nhw mét yéu t6 chi dan s6m cho tinh trang gidm tuéi mau mé, ngay ca khi cac dau hiéu chive nang séng cia BN dudéng nhu cé vé gan nhu' binh thudng. Biéu tr) nhiém oan lactic phy thuéc vao hiéu qua ctia viée phuc hdi lai tinh trang giam tuéi mau mé. Diéu nay dug minh hoa qua phuong trinh cung cp oxy cho mé (tissue oxygen delivery) dugc trinh bay duéi day. Téi uu hoa qua trinh cung cp oxy cho mé can toi mét ndng dé hemoglobin thich hyp dé bao dam viéc chuyén cho oxy toi mé. Thém vao dé, tién ganh cita that la mét yéu té quan trong quyét dinh cung luong tim. Dat duge mét thé tich trong long mach tha dang sé bao dam téi wu hoa thé tich nhat bop (stroke volume) va cung lwgng tim nhdm dap ung nhu cau oxy va cac chat dinh dung khac cia cdc mo. Mét khi da bao dam di tién ganh song cung Ivorng tim van thdp va khéng dapHOLSUC CAP CUU - Tiép cin theo cic phic do mg dugc nhu cdu cia m6, c6 thé st dung dobutamin dé lam tang them nga cung cAp oxy cho té chic va cung lugng tim. DO; = CaO; x CO CaO, = (Hb x 1,34 x SaOz) + 0,0031 Pade CO = SV x tan sé tim Trong dé: DO, (oxygen delivery)= cung cap oxy; CaOz (arterial oxygen content) = t6ng lang oxy chira trong mau dong mach, CO (cardiac output) = cung Iuong tim; Hb (hemoglobin concentration) = néng dé hemoglobin; Sa0, (arterial hemoglobin oxygen saturation) = 46 bao héa oxy cla hemoglobin mau dng mach; PaO; (arterial oxygen tension) = ap lye riéng phan oxy mau d8ng mach; SV (stroke volume) = thé tich nhat bép.Chuang 2: Sée git thé tich nS 194 AULD ynb 200 O ‘oq unyeuaspeson :PA) peu! uga ognin Sung. yeyan] sa ury AeH 966 (uuredog ‘Apu 99 > aVIN ea Sumas § ZdAD aa avy NBT OZ eH NL oz wu RAS ee ey ypip snyog uadnay Xi trf shock gidm thé tich (hypovelemic shock) | j | fi PASE Pha dao ywI>0] | oy ‘Byww 99 Z dV ea BHUW §ZdAD m3 bp np Supp Key on 1yq 99> yuIK 18/8. 6= 4H Op Bugu Ip Ap neo Buoy roY dni (nya urge yotu qHU:PA) Neus Avyo onda ‘pos wary ap apy dpyd UIQ Suny 1px tox ga yodur yu | Sugnp yop ans 194 oft dant Hugyy nyu ‘gua ugnitu a6np wos we99 | 99 = 1P/8 6 > gw aH 46 019eNWwip Sung | Sudan] quia ‘TP/B6 = ‘wey Sunn ypeur yun an (eansoad snouaa [esiu9>) AD "enuo|9 uuneu upénn ysiq IDEN ‘mgo}FoUDY Op Buy, dy maine pu wp 94> 262/%01P uy updnn 9p (OPT MUP NEAL aig wot yw aoroq z 404] Js g quot npupy wea Suna x, sor9qe0) yotur yup upkn Tuonp tq -upnb arin yew yup uxp 20 op neu Key ‘FO la top umn avity u9y> Sugg aép dey ns ov> Bugs upg ‘iu nour Aeys de meus yoeus ‘ya ou Suommn 194 usin up ywos wpry eA 9] 969 ‘Kemp uy yom ‘Buoy 194 oy 19a 19p dp Tueg, | ‘ow Bugp yo" OWN ‘Syww 09 > ow p Z nus wise} Op BuQN SPU O6 > NYY UE YH avn ‘un to Bugs | wey Bugny qn ‘Any wan Buontp aga ga tod 10} a yoeus up Suonpa8 | WOLSUC CAP CEU - Tiép eG theo ede phic dd Bich dibu tr) 481 vot sdc gid thd tich 1a phdi kim soat dugc noudn chay mau va tén hanh bdi phy thoa dang thé tich trong lng mach C6 thd kidm soat dug nguén chay mau chi bang cac thao tac don gan nhu bang 6p dédi voi mot vét thuong md dang chdy mau, song cOng co khi can md tham do cdp cuu dé phat hién va kidm soat nguén chay mau tir vét thuong trong 8 byng hay trong tng ngye Tiin hanh nut mach a8 chm mau sau khi chyp mach (angiographic embolization) 61 vot mach dang chay mau cé thd hou ich trong xi tri vél thuong mach mdu song khong thé can thiép ngoai khoa duge (Vd vo xueng chau phire tap [multiple pelvic fracture] két hop vei tinh trang chay mdu dang tidp didn) Vi vy 4a 36 cdc trudng hyp séc gidm thd tich duge thy thudc chuyén khoa chan thuong xu tri va thudng ngay tai khoa CAp cuu Tuy nhién, \dt ca cdc bac s¥ Gidu tr) cho BN bj bénh ly nang cAn hdi sirc phdi biét phat hign cdc biéu hign lam sang som cua sbc gidm thd tich va én han xi tri truyan dich thich hgp cho BN Phé teh pau renee Foal phn bj nat Cod Sint by bent <20 Co mach ngog vi dé bio tain ding infu ton ede tang quan trong cua co thé (Vd_nio va tim) Nhg (Can ba) Vira 20-40 Gtim tudi mau ede cer quan nhur thin, rudt va tuy Nang (Mit bd) >40 Grim tudi mdu ado va tim MOt quy trinh hudng din xu tri truydn dich didi voi séc gidm thé tich duge trinh bay & Phée 6 2.1 CAn dat it nhat hat catheter tinh mach ngoai bién cd khdu kinh Ion (kim ludn kich tho 14 dén 16G) va/hodc mét catheter tinh mach trung tam kich thuec 8,5F 48 truyén nhanh cho BN dich tinh thé va cdc ché phdm mau Cing c6 thé str dyng cae thidt bj co gidi (a mechanical rapid transfusion device) 64 giup truyén nhanh mau va dich va giup lam giam thoi gian truydn mau va ché phdm hoac mot thé tich lon dich tinh thé cho bénh nhan O BN dang cé tinh trang chay mau udp dién, nén truyén ngay 2000-4000 ml dich tinh thé (Vd. NaCl 0,9% hode Ringer lactat) va mau ahom O Hau hét cdc bénh vién sé truyén 4 don vj mau nhom © Rh (+) (Rh-positive O blood) cho cac BN n& ngoat ludi sinh 48 va BN nam, Truyén mau nhoém O Rh (-) (Rh-negative O blood) cho BN nd cén trong tudi sinh 42 Mau cungChuang 2: Séc gin thé tich nhom (type-specific blood) thueng dugc dung sau khi da truydn 4 don vf mau nhém O ban ddu cho BN Bich didu tr truydn mau cdn dat & BN dang c6 tinh trang chay mdu tiép didn ta duy trl dugc ndng 4d hemoglobin > 8g/dl. Ngoal xiv tr ban ddu bang truyén dich tinh thé va khé! hdng cu, cGng can ap dyng cac bign phdp didu ty phéi hgp cho BN bi sdc gidm thé tich Cac bién phdp didu tr) bé sung nay duoc tom tat trong Bang 2.2, vA dac bidt quan trang 461 voi cae BN can truyén mot thé lich mau Ién hotic dang 6 tinh trang mat mau tiép dién but try Kiém sot durang tha Theo dat huyét déng/ tim mach Truyén tiéu cau/ huyét tuong tuo dong tanh Yeu t6 VIL da duge hoat hoa (Activated Factor VIL) Dang clorua canti (CaCl), clorua magié (MgCl) Mye dich Dé dam bio tink trang trao déi khi thich hyp @ phos va dé dye phong tinh trang hit phat phds Dé phit hign cdc loan nlp va hdr site dich chun thich hgp (inh 2.1) Can thiét do tac dong gay hoa loaing cia diéu try truyén dich tinh thé va ché phim mau cing niu do tinh trang teu thy cde yéu 16 dong mau tis qua trinh chay m4u dang tiép dién Cén diéu chinh thich hgp thor gran prothrombin (PT) va thn gien thromboplastin durge hoat hua ting phin (aPTT) va duy ti sd lugng tigu cau > 50.000/mm? & BN dang c@ tinh trang chay mau udp didn Nén xem xét chi dynh ding @ BN cé tinh trang chiy mau lan toa hay chiy mau dang tigp didn khdng thé cdm mau bang phdu thugt kbt di digu chinh duge ede rt loan déng miu Dé didn chinh tinh trang gidm canxi mau loat ion hoa (ionized hypocalcemia) va giim magié mau do citrat co trong mau truyén (do citrat gin vén son canxs va magia) 9OL SUC CAP COU - Tidp edn theo ede phic dé Cac kg thuat lim 4m (rewarming Ha thin nhigt la mét hau qua thudmg gap khi techniques) (Vd: truyén dich dm, chin truyén mau vai the tich Lon (massive blood dap, dén toa hist. chin nhigt, fam —_transfuston). Ha thin nhigt g6p phin gay ry néng khi fam dm, bom rira cic khoang Joan chire nang tim va 76i loan déng mau co thé bing dich im) Theo dat va/hodc diéu tri cae bien Day Ia céc bién chimg trung gian qua phan chimg hhén quan vor truyén mau nhur ng min dich, BN thong can su dung may ton thuong phér cap hén quan vei thé voi PEEP thich hop dé diéu tr) tinh trang truyén miu (transfuston-ralated acute ton thuong phor cap Hen quan vor truyén lung injury [TRALI}) va céc phan img mau (TRALI), dung thudc dan phé quan va truyén mau, corticosteroid dé diéu try tinh trang co that phé quan nang, phi ha thanh mon (subglottic edema) va céc phan tng phin vé hay qua man (anaphylaxis) Khang sinh Khi céc vét thuong hé ban hay vet thang bj nhiém ban dé dy phong va dieu try cic nhiém tring do vi khuan Corticosteroid Dd ven cde BN nghi ngo cé ton thong thugng than va cdc BN khong cé kha ning dap img thoa dang vin stress. GOI Y NHONG TAI LIEU DOC GIA NEN THAM KHAO THEM Bilkovski RN, Rivers EP, Horst HM. Targeted resuscitation strategies after injury Curr Opin Crit Care 2004, 10 529-538 Cung cdp cdc niéu chi chink trong xit tri séc giam thé tich & BNbj vét thuang do vat tit hode xuyén thaw Kelley OM. Hypovolemie shock: an overview, Crit Care Nurs Q. 2005, 28 2-19 M@t bai tong quan xuc tich vé séc gidm thé tich bao gom ca danh gid vaxte tri ban dau Stein DM, Dutton RP. Use of recombinant factor Vila in trauma, Curr Opin Crit Care, 2004, 10:520-528 Tém tat nhing tiém nang sir dung yéu to Fila tai t6 hop & BN bj chan trong va chay mau dang dién tiénChuong 3 TINH TRANG SEPSIS NANG VA SOc NHIEM KHUAN (Severe Septic and Septic Shock) Marin H. Kollef va Scott T. Micek T inh trang sepsis nang la mét hdi chtrng lién quan véi nhiém tring (infection-induced syndrome) do hau qué cla dip wng viém hé théng gay bién chung di loan che nang déi voi it nhat mét hé théng co quan. O My, mi nam co khoang 750.000 ca nhiém trung huyét (sepsis). TY 1é tr vong lién quan voi sepsis nang giao déng trong khoang tl’ 30% dén 50% va ty Ié nay tang theo tudi cla BN bj tac déng. Mac du phic tap, co ché bénh sinh cla sepsis cé lién quan véi mét loat cdc con dudng tuong tac gay tac d6ng t6i co’ ché kich thich va We ché mign dich, tinh trang tang déng va giam tiéu fibrin. Xt tri cdc réi loan huyét dong dong vai tr quan trong trong Giéu tri sc nhiém khuan. Tut HA xay ra do suy gidm kha nang co mach cla co tron mach mau gay ra tinh trang dan mach ngoai vi. Hdi sc tim mach dé dat duoc cac dich diéu tri (goal-directed cardiovascular resuscitation) da duoc ching minh la mét yéu t6 quyét dinh quan trong giup cai thién ty Ié séng sét clia céc BN bj séc nhiém khudn. Ngoai xir tri cac réi loan huyét déng, diéu tri khang sinh khéi dau thich hop (appropriate initial antimicrobial treatment) cho BN bi septic nang duong nhu ciing [a mét yéu t6 quyét dinh quan trong déi véi két cuc cla bénh nhan. tai da dat dugc nhidu tién b6 trong viéc lam sang t6 cdc co ché sinh ly bénh phwc tap lién quan voi tinh trang sepsis nang va séc nhiém khuan va chung ta da hiéu biét kha sau vé tinh trang bénh ly nay Nhidu loai thudéc mdi citing nhu’ cae chién luge diéu tri méi nham vao co ché gay bénh trong séc nhiém khuan 4a chtrng minh c6 hiéu qua lam giam ti Ié td vong cho BN (Bang 3.7). Thach thc déi voi cac thay thudc hién tai chinh Ia viée tichHOLSUC CAP CUU - Tidp efin theo cde phic db hop céc bign phap didu tri ndi Khoa duge cho la mang 2! Ig ich cai thin ty 16 te vong cho BN vao qué trinh didu tri hdl suc Chién dich cai thién ty ie sdng sot cho BN bj sepsis (The Surviving Sepsis Campaign) a ~ hop vai Vien nghién curu cai thién chat lugng cham soc y 18 (Institute for Healthcare Improvement) tao ra cac “goi" quy trinh xi tri tinh trang sepsis bang (Ihe Severe Sepsis Bundles), cac “goi” quy trinh xir tri nay duge thiet Ke trong nd luc tdi uu hda thet gian, trinh ty, va dich cn dat cho tung tiéu chi xi tri nhu dugc mé ta trong cac hudng dan xt tri cla chién dich cal thién ty 1 séng sot cho BN bj sepsis (Surviving Sepsis Guidelines) Cac Ioi ich mang lai nho sir dung cac phac dé diéu tr toan dién tich hgp gitra on dinh huyét déng som theo myc tiéu (goal-directed hemodynamic stabilization), diéu tr) ai bang khang sinh thich hop (early appropriate antimicrobial therapy), pl hop véi céc bién phap diéu tri bd sung khac d6i voi sepsis nang duc bal dau ngay tai khoa Cap cuu va tiép tye thyc hién tai khoa Biéu tr tich cwe d4 dugec bao cdo qua mot 6 th: nghiém tién cuu (Phac dé 3.4 dén 3.3). Tuy nhién, mot s6 thir nghiém khac dang dugc tién hanh dé danh gia tung phan riéng biét cia cdc hudéng dan didu trj theo dich va vai tro cua alfa drotrecogin hoat hoa trong séc han sé dan t6i cdc thay déi trong cdc khuyén cao digu tri trong tuong lai Y nghia cia viée tién hanh hdi sic truyén dich s6m va tich cye va én dinh huyét déng cho BN sepsis di duge chung minh qua mét th: nghiém ngdu nhién co nhom chung thuc hién tai mot trung tam (randomized, controlled, single-center trial) trén c&c BN nhap khoa Cap cuu cé cac dau hiéu cua hdi chung dap wing viem hé théng (systemic inflammatory response syndrome) va tut HA da dug Rivers va céng su cong bé Dung cac dich tinh thé (Vd NaCl 0,9%, Ringer lactat), trayn khdi hong cau, thuéc co mach va thudc lam tang co bép co tim dya trén theo déi tich cy thé tich trong long mach va cac chi dau danh gid cung cap oxy m6 trong vong 6 gid dau nhap khoa Cp cuu gitp lam gidm téi 16% ty lé tt vong tuyét ddi trong vong 28 ngay dau 6 cdc BN nay. Khac biét chinh trong diéu tr gitra nhom ching va nhém duge can thiép [a & thé tich dich truyén tinh mach str dung cho bénh nhan, sé luong BN can truyén khéi héng cau, chi dinh dung dobutamin va sy hign dign eda cac thanh vién trong nhém nghién ciru tan tuy trong vang 6 gid dau cdp clu cho bénh nhan.Chong 3: Tinh trang nhiém tring nang va she nhiém khudn a Lae ta ier eee cee nt otal CO MAP SYR 1 Thude van mach (Vasopressor) Noradrenalin 0, 05-0, 5 ug/kg/phut + + at Dopamin 5-20 pe/kg/phut + He Adrenalin 0, 05-2 peykg/phit ++ + ae a Phenylephrin 2-10 pwkw/phiit Oo ++ +4 Vasopressin 0, 04 don vi /phiit 0 ++ H+ IL Thude lam ting co bép co tim (Inotrope) Dobutamin 2, 5-10 wg/ke/phuit Ht ot 0 Il. Drotrecogin alpha (hoat héa) 24 pw/ky/gits trong 96 gia VL. Corticosteroids Hydrocortison (+/- 50 mg x 6 gio/lin fludrocortison 50 ie/ngay) V__ Didu trj khiing sinh (Xem Phac dé 3.3) Géc tie tiéng Anh vide tét CO (cardiac output). Cung lugng tim, MAP (mean artertal blood pressure) Huyét ap dong mach trung binh, SVR (systemic vascular resistance) Site can mach hg thing. Thu hién cac phac dé diéu tri giéng nhu cdc quy trinh da duoc Rivers va céng sy mé ta ky lwOng va tién hanh can trong trong nghién ctru cing da dugc cac co sé diéu tr) 4p dung trong thy hanh lam sang Micek va céng su’ 8 4p dung mét “goi" y Iénh duoc chuan héa tap trung vao quy trinh truyén dich inh mach va diéu tr) khang sinh khéi dau thich hyp d6i voi sepsis nang va séc nhiém khudn Cac BN dugc xii tri theo quy trinh nay thuéng can truyén TM mét thé tich dich > 20 mL/kg trong Iuong co’ thé true khi cho ding thuéc van mach, vi vay sé co xac suat phai dng thuéc van mach vao thoi diém chuyén BN tai khoa Bigu tri tich circ th4p hon. Cac BN duce xir tri theo quy trinh néi trén cing co nhiéu co’ may hon dug diéu tri bang khang sinh khdi dau thich hop. Nhu [a két qua cia viée xir tri tich ce duge bat dau Ngay tir khoa Cap cu va duge tiép tuc thuc hién sau dé & khoa Didu tri tichMOI SUC CAP CUU - Tidp edn theo ede. phic dd cure, cdc BN duge ap dung “gol” ¥ jenh xi trl d6i voi tinh trang sepsis nang co thoi gian nam wien ngan hon va nguy co tor vong trong vong 28 ngay thdp hon mét cach cé y nghia théng ké. Gan day cac két qua tong ty cing 43 due bao cdo tur mét nghién cuu da trung tam duge nhom nghién ctu Chién dich cai thién ty 16 s6ng sot cho BN bi sepsis phéi két hop. hop cho céc BN bj séc nhiém khuan duéng nhu [a vén dé mang tinh quyét dinh tién luong cla bénh nhan Ap dung goi y lenh chuan cho cac bac sy Gidu tri ho&c mot s6 phac dd diéu tr) he théng khac dé x tri cdc BN bj nhiém trung nang co thé giup cai thién mot eéch kién dinh kha nang ap dung cdc bién phap diéu tri da duoc khuyén cao va vi vay c6 thé giup cai thién tien lugng cda bénh nhan Khi nhan thue duoc cac quy trinh didu tr) dya trén co’ sG cac bang chung (evidence-based treatment pathways) khéng gay cho BN thém nguy co gi va cling khong lam tang thém nhigu gid thanh digu tri, cn dp dung céc quy trinh nay mot cach chuan héa trong xis tri séc nhiém khudn tai cae co’ so didu tri Tom lai, x tri ban dau thichas Tink trang nhiém tring néng s Chncong 3 queyy yoy ons rou tu puny] ste BuQuy qu end | | > 1D ngUuIUIENgog 7 0€ > 1uooWeUIO HY peur 09 29nu) nau nyu upénay, | unuuedog agoy | | wise s08ury yoip Ary %6'0 TORN By Og YL Tey Sey snjog net] Yotp uana | } Sunp ups upA 2 92 t %0L > FOA9S ‘BywUI> dV Syuut g > dAD | up in narp yop | : <—_———__ ‘ons 0 ‘v0 vo aw) On wea | ~Soos Lees %OL = ONS Bprw 06 = das Byun g = dA SpywU 09 < dV ‘TVaNyo Hoi ‘SHUI Z AWN Spuulg ZdAD. qu 09>avW SHU 96> My WE WH repr] JoSury yoip Avy %G0'0 [DEN By oz. WPYU! NEP LOU snjoq nar] Yip una, (spur seipse>) 19 ‘tue Buna yoéws yun mew 4x0 voy o”g Og (POOIG snoUDs uuoneames us8AxQ) 49196 “unwuEdog. (sumUEdog) Yq ‘uyeUD4peION (ou AN "wet Buna ype yun any dy (sansasd snouDs yomua3) LAD" sla. (opu0yy> wanipo 1OEN "Wulg funn yeu Bugp any dy (amnssaud pooyg VIN nt HET YH (2anssoud poorg aHO¥5KS) ans pH IPE yy” Sup aN 27>c@in theo cde phic do Bénh cin lim sing sepsis va clin diing cae thude van mach mic da 41 dat duge dich did tn truyén dich (Nem Phdc 33.1) Dinh luong néng 6 cortisol ngiu nhién *** Diém APACHE, © Ting nguy ea chay mau (hoge) © Tinh trang hap héi (hoc) © Khong hy vong séng. Xem xét digu tr, Sot qua 28 ngay thay thé (hoge) corticosteroid voi * Khong c6 chi dinh tigu sinh ly hi sure (DNR) ft 66 commay Ia dieu try corticosteroid sé mang lai higu qua Céec tie tiéng Anh vids tit’ APACHE (Acute physiology and chronic health evaluation) Diém APACHE, DNR (do not resuscitate) Khdng c6 chi dinh hai site. '*1 Dexamethason khéng co tc dng giao thoa véi test cosyntropin va 2 mg TM twang durong vei khoang 50 mg hydrocortison "1h dung néu dexamethason khong duge cho Hie du "1 Metyrapon gy block sir chuyén dr cua I-deoxyeortsol thanh cortisol bon CYPLIBIva giv gam ‘hank ning d§ consol. Dé lim test, cho metyrapon duimg uéng var lidu 30 mgrky vav luc 12 gia sing va dinh lugng 11-Jeoxyconisol va cortisol 8 gia sau do Dap ume binh thuimg khi ndng do 11~ deoxycortisol huyét thanh hic 8 pri sing tt 7 dén 22 weidL va néng dp comusol buyét thanh | cefepime, ceftazidime) hoge ‘Carbapenem (Va: imipenem, ‘meropenem, doripenem) hoge Beta-lactam’ chat te ché beta- lactamase (Vd: piperacillin tazobactam) phoi hop vii Fluoroquinolon (Vd. ciprofloxacin hay levofloxacin) hoge Ammoglycosid (Vd. gentamycin, tobramycin, amikacin) phéi hop voi ‘Thudc c6 tac dung voi MRSA (Vd: ezolid, tigecyclin)101 SUC CAP CUU- Tiép efn theo cdc pluie dB GO! Y NHONG TAI LIEU DOC GIA NEN THAM KHAO THEM et al. Effect of treatment with low doses of Annane D, Sebille V, Charpentier C, n patients with septic shock hydrocortisone and fludrocortisone on mortality JAMA 2002,288 862-871 Nehién citu ng nhién ching mink loi ich trén 0) 16 song khudn khong dap tng thich hop khi dimg corticotropin Bernard GR, Vincent JL, Laterre PF, et al, Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001,344:699- 709 Nehién citu mu ngdu nhién ching minh tet ich trén ty 16 te vong & BN dung protein C joat héa trong tinh trang sepsis nang va c6 benh edp tink nang Dellinger RP, Levy MM, Carlet JM, et al, Surviving Sepsis Campaign. international guidelmes for management of severe sepsis and septic shock: 2008 Crit Care Med. 2008,36:296-327 ching déi vai hoi sice va dieu tr] ban déu cho sot @ BN bj soc whiém Céic khuyén cao dua trén co so bang BN bj sepsis nang va soe nhiém khuan Kortgen A, Niederprum P, Bauer M_ Implementation of an evidence-based * standard operating procedure” and outcome in septic shock. Crit Care Med 2006, 34 943-949 Dinh gid mou phic dé sir dung dé hoi site theo diéu tr} som theo muc tiéu, kiém soat dueémys hnyél, ste dung hydrocortison liu khi cd stress, va ste dung protein C phan tog chimg minh cai thién ker cuc lam sang Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign result of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010, 36. 222-231 Kinh nghigm da trang tm thnec hign theo phic gitip cdi thign ket cue cia BN bi sepsis Micek ST, Roubinian N, Heuring T, et al, A before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med. 2006,34:2707-2713 Nehién cttw dinh gid rede — sau cho thay cdi thign tie vong trong vong 28 nga thai gian nam vign 6 BN sc nhiém khuan diege diéu trj theo phac dé thong nhat cia khoa Cap curtChuong 4 SOc CAN NGUYEN TIM (Cardiogenic Shock) Sundeep Viswanathan va Richard G. Bach dc can nguyén tim (Cardiogenic shock) hay séc do tim danh dé chi mét tinh trang voi tuan hoan khéng théa dang va tuoi mau td chirc bj tin hai ch yéu do réi loan chic nang co tim gay nén. Tinh trang suy chuc nang bom cia co tim nay gay mat kha n4ng duy tri tuan hoan cho cac co quan séng con cla co thé va néu khéng duoc digu tn sé dan toi suy nhiéu hé théng co quan trong co thé va tt vong. Séc can nguyén tim dugc dac trung bang tut HA kéo dai (HA tam thu < 90 mmHg) xy ra trong bénh canh giém cung luong tim (thuong gap cung lugng tim < 1,8 Liphuitim® khi khong dung thuéc van mach va < 2,2 Uphiitm® khi dugc ding thuéc van mach) mac di G4 bir Gib thé tich trong long mach (4p luc cudi tam trong cia that tréi > 18 mmHg vashoac ap luc bit déng mach phéi >15 mmHg). Vé lam sang, tinh trang nay goi y BN cé cdc dau hiéu thyc thé phan anh tinh trang gidm tuéi mau hé théng (dugc biéu hién bang cac dau chi lanh va néi van tim, bién ddi y thie, va/hodc thiéu nigu) Tuy nhién, cdc dau hiéu kinh dién néi trén khéng phai luc nao cing duge gap. Mac du da dat duoc nhiéu tién bd Giéu tr trong thei gian gan day, tinh trang sdc tim do suy chic nang bom tim van cé ty Ié tt vong rat cao. Trong s6 céc BN phai nhap vién vi NMCT cap ¢é bién chung séc tim, ty 1é tr vong trong vong 30 ngay dau trong khoang 40 - 50% va ty 18 nay [én tor 55 - 65% trong véng nam dau tien sau nhéi mau co” tim, mac dui ty 1é nay da gidm xudng tuong Ung voi gia tang ty 16 tai tuo mau vanh som bang can thiép mach vanh qua da thi dau (pnmary PCI) déi vei nhdi mau ca tim cdp.MOLSUC CAP CUU - Tiép efin theo cic phic ub BENH CAN Séc can nguyén tim co thé do nhiéu nguyén nhan gay nén (Bang 4.1), song nguyén nhan thuong gap hat la r6i loan chuc nang co tim xy ra trong bénh canh NMCT cdp Tinh trang séc x4y ra & khoang 5-10% cac BN bj NMCT cép Tinh trang nay cé thé xual hién nhu hau qué cla hoac la NMCT that trai ho&c NMCT that phai, mac du NMCT that phai gay r6i loan huyét dong dang ké rt thuong xAy ra khi két hop voi NMCT 6 thanh dui that trai Mure dé nding cia séc do NMCT that trai thong 6 tong quan voi sé lugng co tim bj mat chic nang, mac du cac yéu t6 khac cling cé val tr déng gop Cac bién chung cla NMCT cAp nhu loan nhip tim, thing vach that (ventricular septal defects), réi loan chuc nang co nhu hay vo thanh tim (myocardial rupture) gay ép tim cdp do tran dich mang tim, cling c6 thé kich hoat tinh trang sdc khdi phat. It gap hon, séc do tim co thé la hau qua cia bénh co tim nang (bj dan, phi dai hoac gay tang stress déi véi co tim), viém co tim cp hode bénh van tim nang SINH LY BENH Séc cn nguyén tim thueng xay ra khi tinh trang réi loan chic nang co tim vuot qua mét ngudng téi han. Réi loan chic ndng co tim nay co thé 1a hau qua cla mot 6 NMCT duy nhat co kich thude lon (dién hinh khi 6 nhdi mau tac dng toi > 40% khdi co tim), do sé Iveng tin thang co’ tim cong dén qua nhiéu lan bj nhdi mau, hoac do tén thuong co’ tim lan téa do cac nguyén nan khac gay nén. Khi bj s6c, nhu cau tiéu thy oxy cla co’ tim tang lén do ap luc cudi tam truong cua that tang cao kem voi giam cung cdp oxy do tut HA va giam cung Iueng tim. Cac tinh trang ndi trén sé gay ra mét vong xoan bénh ly ludn quan gay thigu mau cuc b@ va réi loan chire nang co tim tén trién va cudi cing dan toi tu vong (Phac dé 4.1) Diéu tr tinh trang séc can nguyén tim can phar tap trung vao viéc cal dut vong xoan bénh ly nay & nhieu buec khac nhau Van dé con phic tap hon do cé mot thyc té la hau hét BN co tinh trang séc can nguyén tim thu phat sau NMCT cdp bi bénh d6ng mach vanh co t6n thuong dang ké nhiéu mach va diéu nay co thé lam han ché kha nang gia tng co bép bu trix cla nhGing ving co tim khéng bj nhdi mau. Cac nghién ctru quan sat gan day vé day truyén phan wng viém da lam thay ddi nhing quan diém truyén théng vé héi chung nay Thur nhat la, phan sé tng mau that trai trung binh (average left ventricular ejection fraction) & cac BN bi NMCT cép va séc can nguyén tim vao khodng 30% tu la khéng qua thdp nhu diéu dugc dy kién, déng thoi cing thay co nhiéu BN cé phan sé téng mau thdpChuong 4 Séec cin nguyén tim | hon dang ké so voi mtrc 30% song van khéng bi séc do tim. Ngoai ra, sue can mach hé théng & BN bj séc can Nguyén tim thudng khong tang cao va tham chi cn c6 thé thap 15 rét. Didu nay co thé fa hau qua cla hdi chung dap wng viém hé théng nhu' trong séc nhiém khuan va dug cho la cé lién quan voi tang cao ndng dé cytokin va nitric oxid ctia mach mau valhodc cia hé théng va cae chat nay vira gay téc dong lam giam kha nang co bép co tim viva gay tinh trang dan mach. DAC DIEM LAM SANG Trong bénh cénh NMCT cp, tinh trang séc dé xay ra & cc BN la ngudi 06 tudi, phy n& va cac déi tuong cé mat hay nhiéu bénh Iy ndi khoa nang di kem (Vd: BTB, bénh déng mach vanh duge biét tir true, tién sir bj tai bién mach mau nao, va tién sur suy than). Sdéc do tim c6 thé la bién chung cla NMCT cé ST chénh lén (ST elevation myocardial infarction) hay NMCT khéng 6 ST chénh lén (non-ST elevation myocardial infarction), cac tinh trang nay rat thong gap & BN bi NMCT thanh truée. Khi chup dong mach vanh, mach hay bj tan thuong nhat la dong mach lién that trudc, song cac BN bi séc do tim dé bi bénh mach vanh do tén thuong nhiéu mach. Cac dau hiéu va triéu ching cia séc do tim thuéng xuat hién sau khi BN nhap vién (trung binh la 6,2 gid sau khi xuat hién cac trigu chung cia NMCT) va da sé BN bj séc trong vong 24 gi dau. Co khodng 25% BN co thé bj séc tim sau 24 gid’ o6 16 do TMCB co’ tim tai phat gay nén. Can chu y toi nhom chon loc céc BN séc do tim la déi tuong cé biéu hién gidm cung lvgng tim nang va c6 cac bang ching gidm tuoi mau hé théng song lai khéng cé tinh trang tut HA 16 rét. Cac BN nay duoc goi la “BN bj séc tim voi HA binh thudng” (“normo-tensive cardiogenic shock patients") vi day lA cdc déi tyong mac di 6 ty Ié ter vong thdp hon so voi nhém cé tut HA (43% so voi 66%) nhung van co nguy co tl vong cao hon nhigu so véi c&c BN NMCT cp song khéng cé tinh trang gidm tuoi mau méHOISUC CAP CUU - Tidp can theo civ phév da forte Ch dpi Wet teeters ped okey 1, Nhdi mau co tim clip 411 Suy ehire nang bom cia that trai (Left ventricular pump failure) - Onhé: mau ton = Onhdi mau nho @ BN c6 61 loai chite nding that trav tir trude 1. 2, Cac bién chimg co gidi = Tran dich mang ngoar tim gay ép tm cép/va thanh tim ty do ~ Dirt’ 161 Joan chute nang co nu - Nhdr mau co tim that phar - Thung vach that (VSD) - Boe tach déng mach cha 2. Bénh co tim nang/Suy tim i huyét ~ Bénh din co tm (Dilated cardiomyopathy) ~ Bénh ca tim Tako-tsubo hoc bgnh co tim do Stress gay ra (Stress-induced cardiomyopathy) 3. Viem co tim cdp (nhiém tring, adc ti/do thude, thai minh ghép) 4. Dung gidp co tim (Myocardial contusion) S$. Suy van tim ning/cdp tinh = Ho van hat 14 cdp (Vd. do dit day ching [chordal rupture]) - Suy van déng mach chu cdp 6. Tac nghén dong chay ra cita that trai (Obstruction to left ventricular outflow) + Bénh co tim tic nghén phi dai (hypertrophic obstructive cardiomyopathy) ~ Hep van dong mach chu 7. Tie nghén dé diy that - Tran dich mang tim/ ép tm ep do tran dich mang tim = Hep van hat la ~ Unhay nhi trai DANH GIA BENH NHAN Phat hién ngay séc do tim la diu co ban trong xw tri do diéu tri som va thich hop giup lam giém dang ké ty l@ tw vong Cac BN cé HA thdp (< 90 mmHg) can dugc danh gid nhanh dé phat hién ddu higu mach dao (dau hiéu giup chi dan tinh trang ép tim cAp do tran dich mang ngoai tim), cac dau hiéuChuong 4. Sée can nguyén tim cia suy tim aunty {tng &p luc tinh mach canh, phia phéi, nhip ngya phi) va cae bang chung cla gidm tu6i mau co quan dich (dau chi lanh vA ndi van tim, mach yéu, tinh trang y thie u ém, gidm cung yong nude tiéu). Cn tin anh kham tim cn than a8 phat hign cac bénh van tim hay mét sé nguyén nnan co gigi hiém gap gay s6c tim, mac dil trong bénh c&nh NMCT cép hay cung lvgng tim thay Seng ma do hé van hai l& hay do hep khit hay suy van dong mach chi nang co thé bi giém nhidu hoge tham chi khéng thé nghe thay. Phai ghi ngay DTD dé tim kiém cac bang ching NMCT hoae thiéu mau cuc bd co tim cap va dé hé tro cho Iva chon wu tién chi dinh tai tui mau vanh cap ‘etn Can chi dinh xét nghiém cac chi dau sinh hoc (biomarker) tim trong huyét thanh khi BN dén kham cdp citu va lam dinh ky sau dé dé chan doan tinh trang tén thuong co tim cép ngay ca khi DTD khong chan doan duge nhdi mau co tim. Siéu am tim lam tai giuéng thuéng duge chi dinh cang som cang tét sau khi danh gid ban dau BN dé danh gid chire nang that trai va phai, chic nang van tim va 4é loai triv ép tim cdp do tran dich mang tim. Néu duc phat hién, can tién hanh can thiép ngoai khoa cdp cvvu dé xiv tri m6t s6 nguyén nhan co gidi gay suy tudn hoan nhu hé van hai [a cép hoac vo thanh that. Néu van khéng thé xac dinh dugc bénh cn cla séc tim, dat catheter déng mach phdi ngay tai giveng (catheter Swan-Ganz) cé thé gitp chan Goan phan biét séc do tim véi cac loai séc khac. Tuy vay, trong cac trudng hop séc nghi ngg do TMCB co tim cp hay NMCT, tién hanh cac thdm dé huyét déng néi trén khong duoc lam cham tré viéc thuc hién cdc test chan doan xac dinh nhu thong tim trai va chup dong mach vanh. Ngoai hé tro’ cho chan doan, dat catheter dong mach phdi theo dai ap luc bit dong mach phdi cdn gitp huéng dan diéu tr) thuéc van mach va thudc lam tang co bép co tim va 42 dy kién tinh trang huyét dng cia BN sé tét [én hay tdi di tude khi cdc dau hiéu thyc thé dug thé hién 16 trén lam sang. DIEU TRI Biéu trj ndi khoa ban dau BN bj séc cn nguyén tim can duge xt tri cap ctu ngay dé én dinh tinh trang huyét dong nham dé cat dirt vong xoan bénh ly gay gidm tuoi mau mé va nguy co’ tiém an tién trién nhanh téi ton thong tang khong hdi phyc (Phac dé 4.2). Nhing BN nay thudng can dug dat catheter tinh mach trung tam va dugc theo ddi lién tuc ap lye d6ng mach va cung Ivgng nude tigu va duge cho théng khi nhan tao tai mét co’ so chuyén khoa trong bénh vign co day dui va sn sang thyc hién cac bién phap xU tri can thigp ky thuat cao nhu 23(01 SUC CAP CUU - Tidp cain theo vic phic dd can thigp mach vanh qua da (PCI), dat cac thlét bi hé tro tuan hoan va phdu thuat tim mach. Can xac dinh nguyén nhan gay séc tim dé Iva chon phuong phap digu try do ap dung mot sé bién phap can thiép thyong dugc str dung trong mét sé loai séc khac c6 thé gay hai déi voi co tim dang bj r61 loan churc nang cp, nhat la trong bénh cénh NMCT cp Vé diéu tri bang thuédc chéng ngung tap tiéu cau, cing giéng nhu bat ky BN cé héi chung vanh cap khac, cdc BN bj séc can nguyén tim voi bénh can bj nghi van cao Ia do thiéu mau cuc b6 co tim hoac NMCT cdp, phai duge dung du liéu aspirin va xem xét dung sém thudc gay block thy thé adenosin diphosphat néu khéng co chéng chi dinh. Do cé nguy co tiém tang gay tang chay mau trong cuéc mé, co thé cAn tam nging dung thienopyridin toi khi biét ro gidi phau mach vanh va xac dinh duge mét cach tong déi chac chan nhu cau can tién hanh phdu thuat can thiép mach vanh cap ctu, song thuéc can duge su dung cang som cang t6t tru@c khi chi dinh tin hanh can thiép mach vanh qua da Biéu quan trong can ghi nhé 1a nén tranh dung thuédc chen béta giao cdm va thudc uc ché men chuyén angiotensin qua sém chirng nao tinh trang én dinh huyét dong edn chua dat duge. Khi khéng cé tinh trang xung huyét phdi r6 rét, ndi strc bang truyén dich cé thé giup didu tr tinh trang tut HA nhung phai theo dai cn than dé tranh phu phdi va suy hé h4p. Tinh trang tut HA co thé duge didu tr) luc ddu bang mat thuédc co mach (vasopressor), mac du luén can nho rang cac thudc gay co mach ngoai bién thudng sé lam tang thém n@a hau ganh va nhu cau oxy déi voi mdt trai tim dang bj suy Vi ly do nay, nén ding theo kinh nghiém mét ligu thudc van mach thap nhat song van dat hiéu qua dam bao duoc dap ung HA théa dang Mac du con chua co nhiéu bang ching giup xac nhan Iya chon thudc van mach dau tay trong séc can nguyén tim, song cd noradrenalin (liéu khéi dau la 1 dén 40 pg/phut) va dopamin (lidu Khoi dau la 5 dén 20 pg/kg/phut) cO thé duc sir dyng va chinh liéu thudc theo dap ung huyét déng cia bénh nhan Dopamin cé tac déng lam tang co bop co tim két hop voi tac dong gay co mach, gilip bao tén tinh trang tuéi mau than do thuéc gay dan mach mach treo khi dung voi ligu thd. song dung dopamin co thé di kém voi ty 1é bj loan nhip tim cao hon Can lwu y 1a, trong mét nghién cuu gan day tién hanh danh gid két cuc & mot phan nhom gém 280 BN bj séc can nguyén tim tu téng s6 1679 BN bi séc do tat cd cac cn nguyén khi cdc d6i tugng nay duoc phan chia ngau nhién dung dopamin hoac noradrenalin, két qua nghién cu cho thay cé ty I bi cdc su cd khéng mong muén va tw vong trong vong 28 ngay cao hon mét cach cé6 y nghia & nhém dugc dung dopamin so véi nhém ding noradrenalin Néu tinh trang tut HA van khéng dap wng voi didu tri, co thé can thiét su dung két hop nhidu thuédc van machChuong 4 Sée can nguyén tim © BN cé huyét ap tuong adi én dinh (HA tam thu > 90 mmHg) nhung cung lwong tim thap va co bang ching glam tuéi mau mé, dung dobutamin (2,5-10 pg/phut) co thé tao nén cac Io’ ich bd sung thém do thudc cé tac dung lam tang co bép co tim. Do tac dung tiém tang gay dan mach ngoai bién, nén tranh dung dobutamin hoac can st: dung thuéc mét cach than trong 6 cac BN bj tut HA. Milrinon (0,375-0.75 jigikg/phut, c6 thé dung hoac khong cAn dung mét liéu nap 50 pg/kg) la mat thude lam tng co bép co’ tim manh, thudc thuong gay dan mach dang ké va cin duoc str dung mdt cach than trong @ BN cé HA thap va nén tranh ding déi voi BN bj suy than Do thudc van mach 6 cac tac dung phy tiém tang va do ky thuat bom béng déi xung trong long déng mach chi (IABP) hoac st dung cac thiét bi co gidi hd tro budng that mang lai cac tac dung ¢6 I9i, can Iudn xem xét chi dinh hd tro huyét déng sém bang bom béng déi xung trong long déng mach chi (intra- aortic balloon pump support) hoac ap dung sém mat bién phap hé tro’ co gidi khac trong buéng that cho cdc BN bj séc do suy chc nang bom tim tién phat. Tuy nhién, trong mét sé tinh huéng hiém gap khi BN cO nghi van bi bénh co tim phi dai (hypertrophic cardiomyopathy) va séc do tac nghén duong chay ra cia tim (outflow tract obstruction), can tranh st’ dung cac thudc lam tang co bop co’ tim va ky thuat bom bong déi xung trong long dong mach chu va cac thudc co mach ngoai bién nhu phenylephrin dugc coi nh mét thuéc van mach can wu tién lwa chonRéilog Tam tl INOS, Cac tie tiéng Anh vide td INOS nitric oxide synthetase, NO (nitric oxide) oxid mine, LVEDP (left ventricular end-distolic pressure) Ap lye cudi tim trvong thit trai, SVR (systemic vascular resistance). Stic can mach hé thongChuong 4 Séc cin nguyén tim Didu tr] tai tuoi mau: Didu tr] tigu soi huyét va can thiép mach vanh qua da thi dau (Reperfusion Therapy: Thrombolytic Therapy and Primary Percutaneous Coronary Intervention) Khai niém co’ ban trong diéu tr) hién tai di voi séc can nguyén tim & cac BN bj bénh tim do thiéu mau cuc bé la edn phai nhanh chong tién hanh tai tuéi mau trong NMCT cp va tai tao mach vanh (nong mach vanh) sém cho BN bj bénh ly gay tac nghén dong mach vanh va day la cac can thiép then chét gitp lam giam ty 18 tur vong da duge ching minh qua cac thir nghiém lam sang, Do cac nghién ctru ngau nhién vé tai tuoi mau déi voi NMCT co ST chénh lén da cho thay la khi 06 tinh trang séc tim sé gay giam hiéu qua cia diéu tr) tai tudi mau vanh bang thudc tiéu fibrin va cé duoc cc két cuc wu viet hon sau khi tién hanh thanh céng can thiép mach vanh qua da, tién hanh can thigp vanh qua da thi dau (primary PCI) dung luc a phuong phap tai tuoi mau duge uu tién Ilya chon khi cé thé thyc hién due déi voi cac BN NMCT co bién chtrng sdc tim. TY Ié te vong tang lén mét cach dang ké & nhGng BN tri hoan tai tuoi mau cho du su cham tré chi rt ngan tu’ vai phut toi vai gio. Tuy nhién, déi véi nhGng BN khéng thé duoc tién hanh chup mach vanh dung thoi diém, cing c6 mét sé két qua nghién ctru cho thay diéu tri tiéu soi huyét két hop voi bom béng déi xung trong long dong mach chi co thé la mét bién phap tam thoi mang lai loi ich dé co thé cho phép tién hanh tai tuoi mau co” gidi thi hai khi diéu kién cho phép. Tai tao lai dong chay mach vanh (Coronary Revascularization) Cac BN cé bang ching bj héi cht7ng vanh cdp va séc can nguyén tim phai dugc chuyén toi co sé diéu tr) co kha nang tién hanh thong tim trai cap ciru va tién hanh cac thd thuat tai tao lai dong chay mach vanh néu giai phau mach vanh thuan Igi dé thye hién can thiép nay. Két qua thu dugc tir thir nghiém ngau nhién cé tén la SHOCK da so sanh gitva tién hanh thi thuat tai tao lai som dong chay mach vanh voi diéu tri bao tén da cho thay cdc BN co tudi < 75 bi NMCT cp va séc tim khi dug can thiép mach vanh qua da hoac phdu thuat lam cau néi vanh sém sé co gidm ty 1é tle vong 6 y nghia. Cac hu@ng dan diéu tri gan day khuyén cao tién hanh cac tht thuat tai tao lai s6m dong chay mach vanh mot khi co thé thye hién duoc cac can thiép nay cho céc BN nhap vién trong vang 36 gid’ ké tiv khi Khoi phat NMCT ep. Can lwu y rang, do tinh chat phirc tap va muc d6 trai rong cia bénh ly mach vanh @ nhOng BN cé nguy co’ cao nay, 36% s6 BN trong thir nghiém SHOCK duge tién hanh thd thuat tai tao lai dong chay mach vanh bang cach ap dung phdu thuat lam cdu néi dong mach vanh. Cac dé ligu t’ cac nghién ctu khéng ng4u nhién cho thay tién hanh tai tao lai som dong chay mach vanh & cacBS ef " | HOISUC CAP CUU- Tidp can theo cic phic dé BN trén 75 tudi cling co thé mang lai loi Ich cho bénh nhan Cac hudng dan didu tri gan day khuyén cao la chinh cac BN nay cling cn duoc xem xét tién hanh tha thuat tai tao lai som dong chay mach vanh tuy theo tung BN cu thé BN co nghi van bj se edn nguyen tim HA tim thu (SBP)~ 90 ram fo “ — Dinh pid ban diu & nhanb chong dn djnh chite nang sng cho bgnh nhin Ghingay DTD Tim kiém ede bing chimg NMCT cap (ST chénh len, block nhanh trit [men suit Inén], nght ngo NMCT tah sau) Bb sung Oy TKNT (dé diu tr tinh trang guim oxy to chirey HB tr huyét ap Dich HA tim thu cin dat > 65 mmttg, Néu DTD (+) } Digu tr] théu sgt huydvtABP * Chit hi phong can thigp vanh ‘Ahéng sin sing dé lam can thigp ‘mach immediately available Sau di van chuyén BN toi Tin hanb thing tim 436 phir tir ho pdt NMCT- 2-12-18 gio ké tir kh Khoi phat se * Khang e6 eac.chéng chi dinh Khai eiva dia ty chang dong ‘Thich hgp 4é chon tdi tao mach vanh PCI (Chi lim ver dong mach ey nhdi méuy "© Sie dung ster va obctrimah hoge phdu thugt lm chu nbi chp eau (Emergent CABG) (¢én thucomg 3 than, than chinh bode fam disoe PCD TA tim thu (SBP) < 90 mmlig: Dopamnin (5-15 we/ke/phat) LA tim thu (SBP) < 80 mmflg (khi di ding Dopa) Noradeenalin (1-20 yuy/phuny Tat cd cc BN dang duge ding thuée co mach (vasopressors) cin durge theo dos Sp Ie DM xim nh Diu tr ti toi mw tire thi | Ab try huyét dong bing ABP =| nize kem, pha poi) t Néu DTD (-) = ‘Lam siéu dim tim efip ciru ‘Dé danh gra chwre wang thi trav’ thit phat Loat tri cae bién chumg co gio gay hor chung ‘vaoh cap: He van hai Li cip: din co abn, thong, ‘vach lnen thit, vo thanh ned tim, NMICT tit phat ‘Theo dol bing catheter ding mach phdi * Khing dinh can nguyén tim gay se €1<2,2 Upham! PCW > 15 mitt, _ lm tién hinh tai tao mach vanb Tiép tue diéu try hot sue n6s Khoa Néu HA Go dnb, xem vet Hi trg kha ning co bop cua co tm Dobutaman (2, 5-10 uw/phut) Milrtaone (0, 375-0, 75 p/ke’phiit) Trinh cag kd cd tut HA, suy than (Milrizome) a! Se tre * Ca mhde LVAD, chinh gia Khit ming ghép tim ee}Chuong 4. Séc cin nguyén tim 29 Cie te téng Ant vide tit SBP (systolic blood pressure) HLA tim tha; MAP (ancan artenal pressure): HA dong mach trang binh, LW " rt Wea dane met ang Woh. ENTRY dette venturi tht ph, TAT qtr home balloon comet) bongo ach chu chong fv ap lye, PCT (percutaneous coronary ) ong dong mach vin, CAG (comonary artery bypass surge Phat 7 reery), ue AD (left ventreular assist device), Thiét by hd trg that trai long ds thigp mach vane qua da hay n AU Lam edu no1 vanh, LV Cac thiét 6 tre tuan hoan (Circulatory Assist Devices) Bom béng déi xung trong long déng mach chit (Intra-Aortic Balloon Counterpulsation) Catheter cé bong dat trong long déng mach chi (intra-aortic balloon catheter) l& mét thiét bj duc ludn qua mét dong mach (thudng la qua déng mach dui) vao t6i dong mach chi xuéng d& thuc hién viée hé tro’ huyét dong cho BN bi séc. Bang cach bom phing béng lén nhanh bang khi helium ding vao thi diém ngay sau khi déng van dng mach chi va lam xep bong dung Ngay truéc thi tam thu that ké tip, ky thuat bom béng di xung trong long dGng mach chii chi la mot bién phap dé lam tang 4p lye déng mach chu ving trung tam va tinh trang tuoi mau cho cac co quan s6ng cén trong co’ thé (ké ca déng mau déng mach vanh) trong khi lam gidm dong thoi hu génh va nhu cau oxy clia co tim. Hé tro’ huyét dng sém bang kj thuat bom béng déi xung trong lng dong mach chu c6 thé mang lai loi ich nhu mét bude chuyén tiép 4é tién hanh c&c thd thuat tdi tao lai dong chay mach vanh, 48 che phuc héi sau giai doan co tim bi do dan tam thdi (transient myocardial stunning), hoac trong lic cho’ doi tién hanh cac thiét bj hé tro’ co’ gidi ky thuat cao hon déi véi tim hodc cho ghép tim. Ky thuat bom béng déi xung trong long déng mach chi phai duoc xem xét 4p dung nhu’ mét bién phdp can thiép sém déi voi hau hét cdc BN bi séc do tim khi ho khéng c6 chéng chi dinh voi ky thuat nay (Vd: bi suy van dong mach cht nang, bénh ly mach ngoai bién nang, béc tach dong mach chii, co dia dé chay mau hoac sepsis). Cac dé ligu va thoi diém tdi uu dé tién hanh hd tro huyét déng bang kf thu&t bom béng déi xung trong long déng mach chi van cén gay nhiéu tranh cai, song nhiéu chuyén gia khuyén cao la nén tién hanh dat bong trong long dong mach chu trudc hoc ngay sau Khi tién hanh can thiép mach vang qua da thi dau. Cac thiét 6 tro chive nang buéng that dat qua da hodc bang phdu thuat (Percutaneous and Surgical Ventricular Assist Devices) Khi didu tri ndi khoa va tién hanh hé tro huyét dong bang bom béng déi xung trong long déng mach chii van khéng dui dé giup lam 6n dinh tinh trang tuoi mau cla céc co quan séng cén trong co thé, c6 thé can phai dp dung cde dang hé tro huyét dong chuyén sau hon va cdc bién php can thiép nay| HOLSUC CAP CUU - Tidp can theo cae phiic dé cAn duge xem xét ap dyng trudc khi xdy ra tinh trang tén thuong co quan dich khéng con kha nang hdi phuc. Cac thiét bj hé tro chic nang that trai (left ventricular assist devices (LVADs) duge dat bang cach phau thuat hoac gan day 1a bang ky thuat dat qua da, co thé giup lam cai thién co y nghTa cung lugng tim. HA. ap luc bit dong mach phéi, va tuoi mau co quan dich vi vay giup clu mang bénh nhan. O mét BN thich hgp bj séc can nguyén tim, thiét bj hd troy churc nang that trai (LVAD) rat thugng duge sir dung nhu mét bin phap hé tro tam thoi hay nhu mét “bude bac cau” dé cho tin hanh cac bién phdp diéu tr triét dé nhu ghép tim trong ldng ngye (orthotopic heart transplantation) Hién tai, cac thiét bj hd tro chic nang that trai cing da dugc phé chuan dé didu tr) tinh trang séc can nguyén tim trong mot thoi gian dai han hon & cdc BN duge chon loc bj 161 loan chuc nang tim giai doan cudi Cac thiét bi hd tro chtre nang that trai dat qua da xuyén van (percutaneous transvalvular LVADs) (nhu Impella ™ 2,5 va 5,0, Abiomed, Inc) va thiét bj hd tro chic nang that trai dat qua da tir dong mach dui vao nhT trai (percutaneous left atrial-to-femoral artery ventricular assist device) (vi du nh TandemHeart ™, CardiacAssist, Inc) co thé duge dung nap tét hon & cac BN duong nhu la céc Ung vién tdi cho chi dinh dat thiét bi hé tro that trai bang phdu thuat. Thiét bj Impella™ hoat dong theo nguyén tac Iyc xodn Archimedes. Mét catheter dau xoan kiéu duéi lon (pigtail catheter) khdu kinh {on voi mét bom day thu nhé duge ludn qua da vao dong mach dui va dugc day toi van dong mach chi L6i vao tai dau xa cla catheter duoc dat tai vi tri trong budng that trai va thiét bj co thé bom lién tuc voi luu lung mau tu 2,5 dén 5,0 Liphut (tuy thuéc vao kiéu kich thud catheter) vao dong mach chit len. Hé théng TandemHeart™ bao gdm mot catheter co khau kinh lon duge luén vao nhi trai bang cach choc xuyén qua vach lién nhi dé rut mau duge oxy hoa va mét catheter déng mach dugc dat vao trong déng mach dui dé hoan tra lai mau vao co thé, nh& hoat dong cua bom ly tam dat ngoai co thé 66 thé cung c4p duge mot Iuu Ivong dong én toi 5,0 L/phut. Mac du kinh nghiém sir dyng cac thiét bj hé tro’ chire nang that trai ngay mét tng truéng, tuy nhién cac bang chung ching t6 tac dung cia cac thiét bj nay trén tién lvgng cla BN bj séc cn nguyén tim van con rat han ché. Trong mot thir nghiém so sanh ngdu nhién nhé chi c6 26 bénh nhan, thiét bj Impella 2,5 dat qua da dugc nhan dinh la mang lai higu qua tot hon so voi thiét bj bom béng déi xung trong l6ng dong mach chu vé phuong dién cai thién cdc chi sé huy&t d6ng song khdng thdy cé khac biét vé ty 16 tl vong cao trong vong 30 ngay Can co thém cac dé liu vé két cuc cla BN bj séc can nguyén tim str dyng thiét bj nay Cac chéng chi dinh ap dung thiét bj hé tro chire nang that trai bao gdm hé van dong mach chu, béc tach tui phinh déng mach chi,Churong 4: Sb can nguyén tim | 31 bénh ly mach ngoai bién nang, co dia d& chay mau va tinh trang nhiém trung huyét (sepsis). Cac bién ching lien quan voi thiét bj bao gdm chay mau, t6n thwong mach, cae su cé thuyén tac mach huyét khdi, va nhiém trung va chung dat ra cac thach thive lién tuc cdn duge theo dai va xt tri & quan thé BN cé tinh trang bénh ly nang cn hdi str. EP TIM CAP DO TRAN DICH MANG TIM (CARDIAC TAMPONADE) Ep tim cap do tran dich mang ngoai tim (cardiac tamponade) la mot nguyén nhan gay séc dc biét trong dé tinh trang chén ép tim tir ben ngoai gay han ché dang ké kha nang dd day budng that va lam gidm cung lvong tim. Do day la mOt dang séc khéng phai qué hiém gap va co thé hdi phyc nhanh chong, viée phat hién ngay tinh trang nay mang y nghia séng con. Ep tim cap do tran dich mang tim van la mét chan doan lam sang. Cac du hiéu lam sang quan trong khi khdm thyc thé bao gdm cé biéu hién tinh trang mach dao (pulsus paradoxus) (ttc 1 c6 tinh trang giam con sé HA tam thu trong thi hit vao vuigt qua 10 mmHg), cac tinh mach canh néi phéng, va tiéng tim mo tit. Nguyén nhan thuong gap nhat la tran dich mang ngoai tim nhiéu, mac du céc nguyén nhan it gap hon gay suy gidm dé day budng that - nhu co huyét khdi khu tru tai ché gay ép nhi trai 6 BN sau phdu thuat tim cing cé thé gap. Siéu am tim cé thé cho thay cdc ddu higu kinh din cla tinh trang tran dich mang tim nhidu véi cc bang ching chen ép trong thi tam truong déi voi cac buéng tim phai (nhat la that phai) va gia ting cac bién ddi theo chu ky hd hap trong t6c d6 dong chay vao qua van hai la khi do bang Doppler. Khi cé tinh trang tut HA, truyén nhanh dich tinh mach cé thé giup duy tri HA, nhung khéng duoc cham tré tién hanh choc hut dich mang ngoai tim gay tinh trang ép tim bang ky thuat choc hit dich mang tim qua da theo dung choc tir mdi We (choc mang tim theo dudng choc Dieulafoy) hoac md dan luu dich mang tim. Néu chan doan van con nghi van, dat catheter déng mach phdi co thé hitu ich dé cung cdp cac bang chung huyét déng cia tinh trang ép tim c4p voi biéu hién tang “dang ap” (“equalization”) trong ap Ic nhi phai, ap Ie tam trong that phai, ap luc tam trong déng mach phdi va 4p luc bit dong mach phdi KET LUAN Séc cdn nguyén tim la mot tinh trang lién quan véi réi loan chuc nang tim nang né do mét sé nguyén nhan tiém An gay nén, nhung tinh trang nay rt thudng gap trong bénh canh NMCT cp. Séc tim duge két hop voi tile tu vong cao, mac di 4p dung ngay cang nhiéu can thiép vanh som qua da thi GAu déi véi nhdi mau co’ tim cdp duéng nhu dang gitip lam giam tan suat va ty 18 t vong do séc tim. Didu tri t6i vu ddi hdi phat hién som va can thiép2 | | HOISUC CAP CUU - Tiép cGn theo cic phic dé tich cuc bang diéu tri ndi Khoa va cac bién phap hé tro co gidi Ddi voi cac BN bj hdi chung mach vanh cép va séc tim la déi tugng cé giai phdu mach vanh thich hgp, tai tao lai som dong chay mach vanh (revasculariza-tion) da dugc dugc chung minh la bién phap hiu higu gidp cai thién ca ddl voi tién lugng séng sot ngdn han va dai han GOI Y NHONG TAI LIEU BOC GIA NEN THAM KHAO THEM Cheng JM, den Uil CA, Hoeks SE, et al. Percutaneous left ventricular assist devices vs, intra-aortic balloon counterpulsation for treatment of cardiogenic shock a meta-analysis of controlled trials. Eur Heart J 2009, 10°1093 De Backer D, Biston P, Devriendt J., et al. Comparison of dopamine and norepinephrine in the treatment of shock N Engl J Med. 2010;362 779-789 Két qua cha thie nghtem ngdéu nhién SOAP I da dia ra ty Ié xay ra bién c6 66 hat cao hon va ty Ié te vong ngay thie 28 lién quan von sit dung dopamin trong sd cae dteci nhom BN by soc tim Hochman JS Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999,341 625-634 Két qua da cong bo ve nhiing diém chinh cua thie nghigm SHOCK cho thay co giam by Ie tte vong & BN (< 75 tud1) dae phan bo ngau nhién vao nhom tai teat mau som so ven nhom dieu tr1 bdo tn. Hochman JS Cardiogente shock complicating acure myocardial infarction expanding the paradigm Circulation. 2003, 107 2998-3002 Mor bar ting quan vé séc tin bao gém nhiing thang tin mdi hon lién quan te sinh bénh hoc va diéu tri Hochman JS Cardiogentc shock. current concepts and improving outcomes Circulation. 2008, 117) 686-697 Hollenberg SM, Kavinsky CJ, Parrrillo JE, et al. Cardiogenic shock. Ann Intem Med. 1999,131-47-59 Mor bai ting quan dai curong vé séc tim varxtc tri dia theo bang chingChuong 5 SOc PHAN VE (Anaphylactic Shock) Timothy J. Bedient va Marin H. Kollef &c phan tng phan vé (Anaphylaxis) dé chi cdc biéu hién lam sang ac trung va thuéng cé nguy co gay de doa tinh mang BN do hau qua cla phan tng tang qua man xdy ra twe thi trung gian qua globulin mién dich typ E (IgE), phan tng tang qua mn nay cé lién quan v6i qua trinh lam mat cac hat chwa trong bao tuong (degranulation) cla tong bao va bach cAu ai kiém (basophil) gay giai phong cdc chat trung gian hoa hoc nhu: histamin, tryptase, prostaglandin va leukotrien, tinh trang nay xay ra sau khi co thé tiép xc voi mot loat cac chat (di nguyén) Cac phan wng dang phan vé khéng thé phan biét dugc voi phan tng phan vé vé phuong dién lam sang, song cdc phan wng dang phan vé khéng cé lién quan véi vai trd trung gian ca IgE. Tinh trang nay dug gidi thich la do hau qua ciia qua trinh lam mat hat trong bao tuong truc tigp tir cdc tuong bao xay ra doc lap voi I9E hodc do hau qua cla bién ddi chuy&n héa acid arachidonic Cac chat gay kich hoat phan wng phan vé va phan wng dang phan vé rat khdc nhau va duge liét ké trong Bang 5.1. Cac phan Wing phan vé c6 thé xuat hién trong véng vai phut, song thuong < 1 gio sau khi tiép xuc voi chat gay kich hoat. Cac phan ung phan vé nhanh hon xay ra khi tiép xuc theo dudng tiém. Cac triéu chimg ban dau bao gdm dé bing, ngua va cam gidc chét dén noi. Cac biéu hién lam sang ac trung voi mirc 6 nang cé thé thay di é tung BN xuat hién 6 da, mat, duéng hé hép va dudng tiéu hoa, he théng tim mach va hé than kinh trung uong, nhu dugc ligt ké trong Bang 5.2. Tinh trang truy tim mach hoe séc xdy ra & khong 30% cdc truéng hyp va la hau qua cla: (1) Gidm thé tich 33HOLSUC CAP CUU - Tiép edn theo cic phic dé mau do tng tinh th4m thanh mach va mat thé tich trong long mach; (2) Tut HA do dan mach ngoai vi, (3) U'c ché che nang co bép co tim, va (4) Nhip tim cham Cé téi 50% céc BN mé ta c6 cc triéu chung hd hap, ma cac triéu chung nay cé thé tién trién toi suy hd hap do phu né nang dudng hé hép trén, co that phé quan, va phi: phdi can nguyén tim va khdng cn nguyén tim Cac phan tng hai pha (Biphasic reactions) xay ra & toi 20% cdc bénh nhan, duoc dc trung bang xudt hién cdc triéu ching lan thir hai sau phan ung khoi dau tu 1 dén 8 gid’ (mac dui trigu chirng xual hién mun toi 72 gid da dug bao cao) Chan doan dya vao lm sang va cn loai trir mot loat cc chan doan phan biét nhu may day, con hen phé quan nang (status asthmaticus), héi chung “nguéi da dé" (‘red man” syndrome) (do tiém vancomycin), do ngd doc 4 bj von (scromboidosis) (do cac thanh phan gidng histamin cé trong ca bi won thugc loai ca ng, ca thu, ca trich), hoi chung carcinoid, u tly thuong than, tang tuong bao (mastocytosis), ngd dc mi chinh (monosodium glutamate ingestion) va con hoang loan Néng dé tryptase trong huyét thanh (nhat la dudi typ beta) va histamin néu tang cao, cung c4p bang chwng Ung ho chan doan Ning dé tryptase sé tang lén sau khi xay ra su c6 tw 1-6 gid, song néng dé histamin huyét thanh sé gidm di trong véng 30-60 phut. Nong do N- methyl histamin trong mau nuéc tidu 24 gid’ duge so sénh voi gia tri co so lam sau G6 cé thé duge coi la mot test chan doan thay thé hiiu ich. Tat cd cdc BN can dug hdi ky vé tién sur tiép xuc voi tac nhan kich hoat tim an phan tng qua man, song khéng phat hign dugc bat ky mot chat nghi vén nao gay tinh trang phan vé 6 toi 60% cac trvéng hop manenresr)Chuong 5: Séc phan ve | ae Cac nguyen nian pay phan img phan v¢ (anaphylaxis feactions) va pian img dang phan yé (anaphylact reactions) (Cac chat dirye xep cap theo co che ket hyp Ciat net} Cac phan tng phan vé (anaphylaxis) (phan tg qua man trung gian qua IgE) ¢ Thite an (nhit la qua hach [nut], trimg, ca, tom cua va sira bo) © Khang sinh (nhat la penicillin; 4% (+) khi lam test di tmg ciing cho test (+) voi cephalosporin © Vacein © Thudc gay té— gay mé (anesthetics) Insulin va ede hormon khie © Giat d6e t6 (antitoxin) © Mau va cae ché phim mau © Noc cén tring (ong mat, ong bd vé va kién) © Noe rin doc © Latex © Diéu tri min dich gidi di img (Allergy immunotherapy) Cie phan tng dang phan vé (anaphylactoid reactions) (direct mast cell degranulation, altered AA metabolism) «Cac thudc khang viém khéng steroid (nhat 18 aspirin) © Opiat © Sulfit ‘© Thudc cén quang phong xa (radioconstrast media) « Thude gay block than kinh co (Vd: curonium va sucemnylcholin) © Gamma globulin ¢ Khang huyét thanh © Tinh trang ging strc Cée tie tiéng Anh viet tit Ig. (immunoglobulin E); Globulin mign dich typ E, A= Acid arachidome piu tri duge trinh bay trong Phae dé 5.1 va dua trén cac khuyén cao chung cia Vién han lam My vé Di ing, Hen va Mign dich va Trung mon My vé Dj ing, Hen va Mién dich (the joint recommendations of the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma and Immunology). Biéu tr) bang thuéc bao gdm dung adrenalin (epinephrine) dé xir trl cac tac d6ng trén ho hap va tim mach cua tinh trang phan vé, va phong téa cac tae dong cia histamin bang thuéc6 | HOLSUC CAP CUU - Tiép edn theo etic phic dé khang thy thé histamin 1 (H1) va 2 (H2) Khéng co chéng chi dinh 46i vei six dung adrenalin, va 6 rat nhidu nghién ciru cho thay la adrenalin 4a khong duge sir dung dung muc trong xt tri cp civ tinh trang phan vé, ma cham tr dung adrenalin sé gay tinh trang s6c va suy hd hap cho bénh nhan Trong mOt nghién ctu cla Korenblat va cong sy’, 70% BN co biéu hién triéu chung nang can it nhat hai ln tigm adrenalin SU dyng steroid duGng tinh mach khdng 6 vai tro gi trong diéu tr) cp ctru phan ung phan vé song co thé giup dy phong dugc cac phan ung pha 2 co thé xay ra toi tan gio’ thu 72 sau cac bidu hign ban ddu cia phan Ung phan vé. Steroids duge cho voi liu khoi dau tu 1-2 mg/kg methylprednisolone theo duéng tinh mach (hoac mét steroid khac voi lidu tuong duong) va duge dung lién tuc trong 4 ngay (theo dung tinh mach hay duéng uéng). Khi ra vién, BN can duge gti kham thay thudc chuyén khoa dj ung dé lam test tim dj nguyén va theo dai Can c4p cho BN cdc bom adrenalin tu tiém dung & nha (home epinephrine self-injectors) (vi du: EpiPen) Pe (ONL Gas uecn ay Prmroran unica woe Mar aG rh rg OTUs Mat Hg tidu hoa Ho hap Newa Buon nén/nén Kho tho Chay née mat la chay Tieng rit (stndor)wheezing/khan tiéng Xung huyét két mac Dau bung Kho nuot Phi quanh 6 mit Phu phos Hg thong tim mach Da 1G than kinh Tut HA Newa Lo Hing va “cam grdc chét dén noi” Nhip tim nhanh (nhyp tim Do da Thoang ngat (presyncope va ngat) cham trong tinh trang ning) ~— May day Co giat Loan nhip im Phi Quinck Ngimg tim (angioedema)Chi dinh digu tr edp cit nzay cho tit c4 cée BN 6 trie ho tw/e may €6 thé én trién nhanh tai tinh trang sé, ssuy ho hi 4jnh tuyGt Abi vot dung epinephrin (adrenatiny ‘hip, tim mach hay dirong teu héa ning do cdc: | lip va tir Vong, va khi BN khéng c6 chéng chi | ‘Nehi ngé tinh trang suy hé hip ning xy ra dén nor (tiénge rit thanh quén, ran co thi, | tho hank, kho tha, kho musty | Khong Co * Dit BN otrthé nim ngia D&tNKQ ngay tire khic do chim tré © Dat duong truyén TM vor kim truyén khiu co thé lam ting mite dé kho khi dt ‘kin Ion (song khéng duge chim tré sir NKQ | | | | | | ding adenatiny | ea i lp ie | # Theo dai lién tye HA, tin s6 tim, d6 bio thyroidotomy) néu ditimg thé bi phit hoa oxy va ede trigu ching ho hay } né nang Adrenalin TB 0,3-0,5 mg 1 1 000 vio mat trvde hotc bén cua | dit Tiém nhac Iai sau 5 phitt néu edn (liu thit hai €6 thé Didu tr] cho tit ea ede BN bing | pes ba ligu dtu) thude khang thy thé H, va Hy | DOI VOI CAC BN CO TRIEU CHUNG NANG HAY 1) Diphenhydramin (H,) 25-50mg_ KEM DAP UNG VOI DUONG TIEM BAP CAN CHO. TM va | ‘Adrenalin TM 0,1-0,2 mg (trén ImL 1 1000 véi 9 mL NaCl Ranitidin (H.) 50mg TM hode | 09% = [0,1 mg/mL] 1-2 phut tor kh €6 dap img 2), Famotidin (H:) 20 mg TM NEU CO TINH TRANG TUT HUYET AP CAN CHO, 1-2 L NaC} 0,9% truyén TM nhanh_ Dip img lim sing? Néu BN dang ding thude chen béta giao cim 6 nha 1) Glucagon 1-2 mg TMITB x 5 phiit/Iin t6i khi 6 tée dung ‘Néu tinh trang tut HA tiép dign 1) Bat diu truyén adrenalin TM lin tue vor lidu 0,1-1 meg ky phut diéu chinh lidu tot khi o6 tae dung. 2) Tiép tuc én hanb héi sire truyén dich tich eye (qua may tmyén dich tc d6 nhank néu sin c6) Khi ede tr/c hé hap tiép din va néu BN khdng phal dit NKQ 1) Khi dung (nhaled) mot thude chu van beta (beta-agomists) (Vasalbuterol) 0.5 mi logt dung dich 0,5% pha trong 2,5 mL. NaCl 0,9% dé khi dung cho BNy 15 phat/lin KhongOL SUC CAP CUU - Tiép ef then ede phac do GO! Y NHUNG TAI LIEU DOC GIA NEN THAM KHAO THEM Parameters, American Academy of Allergy, Asthma and Immunology, Amencan College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology The diagnosis and management of anaphylaxis an updated practice parameters, J Allergy Clin Iinmunol. 2005,115 $483-S523 Cée Khuyén cio chung vé dink nghhia, nguyén mln, biéu hi cho BNphan ung phan vé va phan ng dang phan ve Korenblat P, Lundie MJ, Dankner RE, et al. A retrospective study of epinephrine rnaphylaxis how many doses are needed ” Allergy Asthma Joint Task Force on Practice ‘én, chan doan va diéu tr administration for at Proc 1999 20 383-386 Tang ket hit cirw lai 105 trig hop sie phn vé dé xtic dj mice a nang vi so heang Adrenalin tidm wong ting can dé lam het trigu chieng qua man Sheikh A, Shehata YA, Brown SG, et al Adrenaline for the treatment of anaphylaxis. cochrane systematic review Allergy! 2009.64, 204-212 Mét bai tong quan duea trén cor sé bing ching he thong ve sie dung Adrenalin cho diéu iri soc phan véChuong 6 CAC NGUYEN NHAN Co’ GI01 GAY s6c (Mechanical Causes of Shock) Howard J. Huang éc do nguyén nhan cor gidi (mechanical shock) 6 thé bj thuc day béi mét loat cdc héi ching gay tinh trang mat dién tich mat cdt ngang mach phi c4p tinh, hodc do tc nghén true tiép cla hé thong mach phéi (pulmonary vasculature) hoc do co that mach phdi théng qua su diéu phdi cilia cdc chat trung gian hoat mach (vasoactive mediators). Hau qua cudi cing la gay gia tang strc khang mach phdi cdp tinh va tinh trang nay sé dan toi Keo dan cng budng that phai (right ventricular strain), suy that phai va séc. Sée do nguyén nhan co’ gidi (Mechanical shock) cing cén dugc goi dui ten séc do téc nghén (obstructive shock), va hai thuat ng nay duge su dung thay thé cho nhau trong y van. Ep tim c4p do tran dich mang tim dug thao luan trong Chuong 4, cing cé thé duge xem xét nh mét nguyén nhan cor gidi gay séc. Tuy nhién, sinh ly bénh cla tinh trang nay khac biét hoan toan 80 voi thé séc do tic nghén khac dugc thao luan & day. Mac du cac bénh can gay séc khac nhau duoc thao luan tach biét trong cuén sach nay, song mot didu quan trong cn ghi nhén la trén mét BN c6 thé thay nhiéu loai séc duoc thé hién ding thoi & cng mét thoi diém Chuong nay sé tap trung thao Iuan 4 bénh can chinh cla séc do Aguyén nhn co hoc: (1) Tac mach phéi mie dé nang (massive pulmonary embolism); (2) Tac mach hoi (air embolism); (3) Tac mach do mo (fat embolism), va (4) Tac mach do dich 6i (amniotic fluid embolism). Mire dé ton hai huyét dong do bat ky mét nguyén nhan nao trong bén loai séc do nguyén nhan co gidi néi trén gay nén sé duge quyét dinh bdi: (1) Mure d@ nang cla tinh trang t&c nghén mach vafhoae co that mach cla hé thong dong mach phi; (2) Céng nang (performance) va kha nang du troy cla that phai; va (3) 39» CUU - Tiép ean thea ciic phic dé Bénh ly tim phdi co ty truae VI dy, tac mét nhanh mach phdi thuong khong gay nguy hiém tinh mang cho mot phu n@ sau dé (ngudt tryéc dé hoan toan khée manh) song lai co thé gay séc nguyén nhan co gidi do tang ap dong mach phdi tir roc va chirc nding that phai & mw ranh gidi Tuan hoan phdi trong dieu kién binh thydng la mot vong tuan hoan 5 strc can thép, c6 dung tich cha cao Noi chung that phai khOng thé bu try duc cAp tinh d6i vor mét ap lye dong mach phdi trung binh (mPAP) > 49 mmHg Vi vay, phat hién duge gia trl mPAP > 40 mmHg song khong cé cac dAu hiéu lam sang ca suy that phai sé gol y co nguyén nhan ban cép hoac man tinh gay lang 4p dong mach phoi Khi khong co bénh ly tim phdi c6 ty. true. tng hau ganh that phai va ap lye dong mach phdi trung binh co tuong quan truc tidp voi muc dé nang cla tac mach va/hoac co that mach phdi Cac dau hiéu siéu 4m tim ctia rdi loan chuc nang that phai cdp co thé duge thy rd khi c6 tinh trang giém tu 25 dén 30% dién tich mat cat ngang nén mach phdi. Tuy nhién, muc dé tac nghén mach can thiét dé gay tén thuong huyét déng va sdc c6 thé thap hon rat nhiéu & mot BN co bénh ly tim phdi tw trvocCincong 6. Cée nguyén nhan co gibt COTTA Oe | Tie nghén co gidi J hau ganh that phar t Thé tich + Ap luc cudi tim trucmg that phai Tap lye ni phar {hdi hru tinh || thé tich téng mau etia that phat | {hot uu tinh mach 4 strc khéng mach phdi Dain that phai interventricular [ { Tuc mau 1 | ES Plate Co thit mach poi nu ci O» cua co tim ning || mach vinh, that tat {1ién ginh that trai 1 Compliance Bénh tim-phai cé tir tre cua { kha ning co bép cua that phai + that trét | Cung Iugng tim Sbetro ‘Tray mach (Circulatory collapse) Tie-vongSea cou Tidp vn theo cdc plidc dd Néu khang duge can thiép lich cyc va kip tha, gia tang suc can mach phdi cdp tinh vuot qua kha nang bu tru cia that phal sé thc day mét day truyén cac sy c6 gay hal voi két thuc bang tinh trang dc he vt truy mach a ti vong Phe dé 6.1 minh hoa ban chat tac dong tuong ne cua nhidu yéu tg tham gia gay séc do tée nghén Xt tri thanh céng hol chung soc do nguyén han co’ gidi phy thudc vao viéc phat hién som va nhanh cheng tién hanh cac bién phat didu tr) hd tro dé tai hdi lai tinh trang dn dinh huyét dong va dy phong réi loan chue nang co quan dich Cac ddu higu lam sang thudng gap trong cac tinh trang séc do nguyén nhan co’ giéi bao gdm nhip tim nhanh, tut HA, va cac dau hiéu giam tuoi mau co quan dich (Vd. gidm thé tich nuéc tiéu/gio, cc dau chi lanh va ndi van tim, va bién déi tinh trang y thie) Kham thu thé cé thé cho thay 6 cac déu higu suy that phai mat bu nhu' tinh mach cé ndi phdng, tiéng thdi do hé van ba la, gia tang cudng dé tiéng T2, phan hdi gan tinh mach cé (+) va dau higu Kussmaul. Réi loan diéu héa dé dat dugc mirc dé tuong xtrng gitra thong khi va tu6i mau sé gay giam ndng dé oxy mau va thé nhanh. Trong cac trong hgp kich tinh, rung that, v6 tam thu hay c6 hoat d6ng dién hoc song v6 mach C6 thé la biéu hién khdi phat cua tinh trang nay Vé phuong dién chan doan, nhip nhanh xoang thuéng dugc gap khi ghi DTD, cé kém theo hay khéng 6 cac bién déi goi y tinh trang cang dan (strain) va thigéu mau cuc bé co tim that phdi Cac dau hiéu siéu am tim cia r6i loan chic nang that phai bao gdm dan that phai, gidm déng (hypokinesis), ho van ba Ia va det phang vach lién that. cing co thé duoc biéu hién Cac dau hiéu can 4m sang thong gap Ia ha natri mau, tang ndng do peptid gay tang thai natri nigu nguén géc nao (BNP), va tang cdc chi ddu danh gia tin thurang tim (troponin T hoac 1) Cac phan sau day sé dé cap toi cdc dac diém riéng, sinh bénh hoc, va xu tri déi v6i bén hdi ching séc do nguyén nhan co’ gidi thuéng gap. Bang 6.1 trinh bay mét bang danh sach cac yéu té nguy co thudng gap, cac dau hiéu va trigu ching biéu hién ca ting hdi ching nay.