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Suy Hô Hấp ở bệnh nhân chấn thương 2012
Suy Hô Hấp ở bệnh nhân chấn thương 2012
ABC
A: AIRWAY B: BREATHING C: CIRCULATION
Con th khong ?
Con th khong ?
anh gia trong 5 giay
Nhn
Mot ngi
Hai ngi
Thyroid Cartilage
Cricoid
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Tm cac dau hieu cua suy ho hap: moi tm, phap phong canh
mui, co keo c ho hap Co can at noi kh quan ngay hay khong? Co can th may khong? Neu benh nhan noi bnh thng la mot dau hieu chng to ng th toan ven.
Nhn trong mieng benh nhan xem co mau, chat oi, manh xng gay, rang gay, rang gia va vat la khong. Lang nghe benh nhan th co tieng rt hay kho khe khong. Tm cac dau hieu cua ton thng ng th: chan thng au, mat, co, ngc, bung...
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG: Rang gay, vat la, dch tiet, Gay tac nghen ng th, co the chat oi lot vao kh quan
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG: Li Tut li la nguyen nhan gay tac nghen ng th thng gap nhat benh nhan hon me Gap benh nhan beo ph, gay tac nghen ng th vung ha hong va tren nap thanh quan
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:
Gay xng ham di co the gay tac nghen mot phan hoac hoan toan ng th, lam cho benh nhan th kho khe
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:
Gap benh nhan bong, ht khoi trong am chay Gap benh nhan chan thng kn hoac h vung co
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:
Chan thng kn vung co co the gay chan thng thanh quan, gay tac nghen mot phan hoac hoan toan ng th t ri thanh Chan thng kn hoac h vung co co quan kh the gay t ri thanh quan kh quan quan mot phan hoac hoan toan. Thng phai at noi kh quan qua may noi soi phe quan.
CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:
Ht mau va Gay tac nghen hoan toan chat oi vao ng th. ng th Ht lng nho chat oi co o acid cao gay bong hoa chat va ARDS. Noi soi phe quan e lam sach chat oi.
CAC BIEN PHAP KIEM SOAT NG TH M thong ng th khi benh nhan khong chan thng cot song co Thao tac nga co (Head tiltchin lift)
T the "sniffing"
Truc ng th
Mouth A A
B C B
Pharynx
Trachea
Extend-the-head-on-neck (look up): aligns axis A relative to B Flex-the-neck-on-shoulders (look down): aligns axis B relative to C
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CAC BIEN PHAP KIEM SOAT NG TH M thong ng th khi nghi ng chan thng cot song co Thao tac an ham (Jaw thrust)
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Tac nghen hoac nguy c tac nghen ng th: bu mau ln vung co, chan thng thanh quan, kh quan, bong nang, th
III
IV
Class I: Uvula/tonsillar pillars visible Class II: Tip of uvula/pillars hidden by tongue Class III: Only soft palate visible Class IV: Only hard palate visible
Den Herder, et al. Laryngoscope. 2005;115(4):735-739.
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M KH QUAN M kh quan c thc hien khi at noi kh quan that bai, trng hp khan cap choc kim to vao mang nhan giap e thong kh trong khi ch m kh quan.
Choc kim to vao mang nhan giap: chu yeu cung cap oxy, khong thai CO2
SHH-OXY THERAPY.pdf 47
Nguyen nhan gay giam oxy mau benh nhan chan thng
Nguyen nhan gay giam oxy mau benh nhan chan thng
Giam thong kh Mang sn di ong Ngo oc heroin Chan thng cot song
KMM: PaCO2 ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy roi tang thong kh phe nang
Nguyen nhan gay giam oxy mau benh nhan chan thng
Bat tng hp thong kh / ti mau Giam the tch mau Vt cao qua PEEP cao qua KMM: PaCO2 bnh thng
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, bu ap the tch tuan hoan, ieu chnh thong kh
Nguyen nhan gay giam oxy mau benh nhan chan thng
Shunt tai phoi Tran kh mang phoi Tran mau mang phoi. KMM: PaCO2 bnh thng
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, dan lu mang phoi
Nguyen nhan gay giam oxy mau benh nhan chan thng
Shunt tai phoi Xep phoi Viem phoi ht. Dap phoi. Thuyen tac m. ARDS. Qua tai tuan hoan KMM: PaCO2 bnh thng
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, th may co cai PEEP
Nguyen nhan gay giam oxy mau benh nhan chan thng
Mat mau Xuat huyet KMM: PaCO2 bnh thng
Nguyen nhan gay giam oxy mau benh nhan chan thng
Giam cung lng tim Giam the tch mau. Chen ep tim. Tran kh, tran mau mang phoi.
KMM: PaCO2 bnh thng, khi co toan chuyen hoa ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, sau o ieu tr nguyen nhan
Nguyen nhan gay giam oxy mau benh nhan chan thng
c che ho hap te bao Ngo oc cyanide Ngo oc kh CO
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, sau o dung Nitrit - thiosulfate oi vi ngo
Nhng ton thng long ngc gay suy ho hap co the dan en t vong nhanh chong neu khong chan oan va x tr kp thi
Tran kh mang phoi ap lc Tran mau mang phoi lng ln
Mang sn di ong
tui d tr (FiO2 > 60%). PaCO2 > 45 mmHg va kh mau ong mach co toan ho hap.
(pH 7,35 - 7,45, PaO2 80 - 100 mmHg, PaCO2 35 - 45 mmHg). Vi t bien chng nhat, bao gom on nh huyet ong va han che ton thng phoi do th may. e han che ton thng phoi do th may FiO2 60%. Ap lc bnh nguyen cua ng th (P plateau) < 30 cmH2O. Cai PEEP mc thch hp.
Cai at ban au
Mode th: A/C.
Vt: 8 ml/kg.
Duy tr kh mau ong mach trong gii han bnh thng (pH 7,35 -
7,45, PaO2 80 - 100 mmHg, PaCO2 35 - 45 mmHg), Vi t bien chng nhat, bao gom on nh huyet ong va han che ton thng phoi do th may. e han che ton thng phoi do th may
FiO2 60% Ap lc bnh nguyen cua ng th (P plateau) < 30 cmH2O Cai PEEP mc thch hp.
kiem tra xem bong chen noi kh quan co b thung khong, day may th co b thung hoac cac cho noi a kn cha. Giam dan FiO2 tuy theo SpO2, duy tr SpO2 95 - 98%. PEEP: tang mc PEEP khi benh nhan co bien chng ARDS.
Hoi chng suy ho hap cap nguy kch (Acute respiratory distress syndrome ARDS)
ARDS la phan ng viem tai phoi, gay ra tang tnh tham cua hang rao phe nang mao mach Nguyen nhan thng gap nhat benh nhan chan thng la dap phoi.
PaO2 / FiO2 200 bat ke mc PEEP X quang phoi co ton thng dang phu mo ke phe nang 2 ben Ap lc mao mach phoi bt 18 mmHg hoac khong co bang chng lam sang va X quang cua gia tang ap lc nh trai (Loai tr phu phoi do tim).
Bong.
Truyen mau va cac che pham cua mau.
Th may benh nhan chan thng so nao Tac ong cua th may len bn CTSN: giam ap lc ti mau nao do giam cung lng tim, giam huyet ap ong mach trung bnh tang ap lc tnh mach trung tam lam cho lng mau t nao ve tim giam, lam tang ap lc noi so. V the bn CTSN co th may can c duy tr cung lng tim va huyet ap bnh thng.
Th may benh nhan chan thng so nao Muc tieu th may benh nhan chan thng so nao la duy tr: - PaO2 bnh thng (80 100 mmHg) - PaCO2 bnh thng 35 40 mmHg neu khong co tang ap lc noi so, 30 - 35 mmHg neu co tang ap lc noi so.
mc toi a10 cmH2O. Neu can phai dung mc PEEP cao hn can nhac th may tan so cao.
Th may benh nhan chan thng so nao Tang thong kh: c s dung e giam ap lc noi so trong phu nao Tang tan so th hoac Vt e PaCO2 t 25 30 mmHg trong 30 phut c s dung sau khi a dung an than, dan lu dch nao tuy va dung mannitol nhng cha giam c ALNS. Khong s dung bien phap nay keo dai, v tang thong kh gay giam ALNS thong qua c che co that mach mau nao gay giam lu lng mau ti nao, lam nang hn tnh trang thieu mau nao.
Thuoc thng c s dung la giam au nhom a phien (opioid) va an than nhom benzodiazepin. Co the phoi hp ca hai loai thuoc tren.
Bai giang tai t trang web HYDTPHCM www.yds.edu.vn Bo mon HOI SC-CAP CU-CHONG OC
phan Tai nguyen hoc tap
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Straight-Blade Laryngoscope
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A
A
B C B
Pharynx
Trachea
Extend-the-head-on-neck (look up): aligns axis A relative to B Flex-the-neck-on-shoulders (look down): aligns axis B relative to C
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Epiglottis
Glottic opening
Arytenoid cartilage
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Tracheal Intubation
Indications
Inability to ventilate the unconscious patient After insertion of pharyngeal airway
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Tracheal Intubation
Recommendations
Intubate as soon as possible after ventilation
and oxygenation in cardiac arrest Intubation should be done by most experienced person Do not take longer than 30 seconds per attempt Auscultate the thorax and epigastrium after intubation
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Tracheal Intubation
Complications
Traumateeth, lips, tongue, mucosa,
vocal cords, trachea Esophageal intubation Vomiting and aspiration Hypertension and arrhythmias
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Esophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
E
Distal End
C = tracheal tube; ventilation through open end if proximal end inserted in trachea D = pharyngeal cuff; inflated through catheter = E F = esophageal cuff; inflated through catheter = G
H D B
Proximal End
G
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D
A = esophageal obturator; ventilation into trachea through side openings = B D = pharyngeal cuff (inflated) F = inflated esophageal/tracheal cuff H = teeth markers; insert until marker lines at level of teeth
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M KH QUAN M kh quan c thc hien khi at noi kh quan that bai, trng hp khan cap choc kim to vao mang nhan giap e thong kh trong khi ch m kh quan.
Airway: Surgical
Tracheostomy: Not usually for emergencies, need experience, knife and a tube Percutaneous Tracheostomy: Not for emergency situations
Hemothorax
Massive Hemothorax
Can be result of lines or
thoracentesis Limited diagnostic use of thoracentesis Chest tube is intial management Larger size tube 40FR If large quantity or persistent then surgery