1

B Y T

HNG DN CHN ON V IU TR

MT S BNH THNG GP TR EM

(Ban hnh km theo Quyt nh s 3312/Q-BYT ngy 07/8/2015

ca B trng B Y t)

H Ni, 2015

2

CH BIN TP

PGS. TS. Nguyn Th Xuyn

NG CH BIN

PGS.TS. L Thanh Hi

PGS. TS. Lng Ngc Khu

BAN BIN SON

GS.TS. Nguyn Gia Khnh

GS.TS. Trn nh Long

PGS.TS. Phm Nht An

PGS.TS. Nguyn Ph t

PGS.TS. Phan Hu Nguyt Dim

PGS.TS. Trn Minh in

PGS.TS. on Th Ngc Dip

PGS.TS. Khu Th Khnh Dung

PGS.TS. H S H

PGS.TS. L Thanh Hi

PGS.TS. L Th Minh Hng

PGS.TS.Nguyn Th Qunh Hng

PGS.TS. V Minh Phc

PGS.TS. L Tn Sn

PGS.TS. Nguyn Vn Thng

PGS.TS. Phm Vn Thng

PGS.TS. Nguyn Th Diu Thy

PGS.TS.o Minh Tun

PGS.TS.Ninh Th ng

PGS. TS. Bi Vn Vin

TS. BS. Nguyn Th Hng Giang

TS.BS. Nguyn Th Vit H

TS.BS. Nguyn Th Thu H

3

TS.BS. Trn Th Hng H

TS.BS. L Th Hng Hanh

TS.BS. Trn Kim Ho

TS.BS. Phan Th Hin

TS.BS. Nguyn Phm Anh Hoa

TS.BS. Trng Th Mai Hng

TS.BS. Nguyn Thanh Hng

TS.BS. Cao V Hng

TS.BS. Nguyn Th Thanh Hng

TS.BS. Nguyn Thu Hng

TS.BS. Bi Ngc Lan

TS.BS. Phng Tuyt Lan

TS.BS. Hunh Thoi Loan

TS.BS. Trn Th Chi Mai

TS.BS. Nguyn Vn Ngoan

TS.BS. Phan Hu Phc

TS.BS. Bi Phng Tho

TS.BS. Lu Th M Thc

TS.BS. Dng B Trc

TS.BS. H Mnh Tun

TS.BS. T Anh Tun

BSCKII. Nguyn Th Diu

BSCKII. Trnh Quang Dng

BSCKII. L Th Cng Hoa

BSCKII. Nguyn Th Minh Ngc

BSCKII. L T Nh

BSCKII. Phan Huy Thun

BSCKII. Nguyn Minh Tin

BSCKII. Trn Kinh Trang

BSCKII. Trnh Hu Tng

4

Ths.BS. Nguyn Th Vn Anh

Ths.BS. L Qunh Chi

Ths.BS. V Ch Dng

Ths.BS. L Ngc Duy

Ths.BS. L Th H

Ths.BS. L Th Thu H

Ths.BS. Trn Thu H

Ths.BS. Trnh Th Thu H

Ths.BS. Thin Hi

Ths.BS. Nguyn Thy Hng

Ths.BS. o Trung Hiu

Ths.BS. Nguyn Th Mai Hon

Ths.BS. u Vit Hng

Ths.BS. Chu Lan Hng

Ths.BS. Nguyn Mai Hng

Ths.BS. Nguyn Th Mai Hng

Ths.BS. Nguyn Ngc Khnh

Ths.BS. Nguyn Vn Lm

Ths.BS. Nguyn Ngc Qunh L

Ths.BS. Trng B Lu

Ths.BS. Nguyn Kin Mu

Ths.BS. Quch Thy Minh

Ths.BS. Thnh Ngc Minh

Ths.BS. Nguyn Hong Nam

Ths.BS. Nguyn Trn Nam

Ths.BS. Thi Thin Nam

Ths.BS. Cn Th Bch Ngc

Ths.BS. Nguyn Hu Nhn

Ths.BS. Giang Trn Phng

Ths.BS. L Hng Quang

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Ths.BS. Phm Th Thanh Tm

Ths.BS. Phan Thnh Th

Ths. Tm l Nguyn Th Hng Thy

Ths.BS. V c Tr

Ths.BS. Nguyn Th Ngc T

Ths.BS. H Anh Tun

Ths.BS. Nguyn Minh Tun

Ths.BS. Trn Anh Tun

Ths.BS. Trn Th Hng Vn

Ths.BS. Nguyn Minh Tr Vit

Ths.BS. Chu Vit

ThS.BS. Phng ng Vit

BSCKI. Bi Vn

BSCKI. L Nht Trung

BS. Bch Vn Cam

BS. Ninh Quc t

BS. L Th Thu Hng

BS. Thc Thanh Huyn

BS. Trn Th Bch Huyn

BS. Trng Hu Khanh

BS.Nguyn Thu Vn

T TH K

Ths.BS. Trn Vn Hc

Ths.BS. Nguyn c Tin

Ths.BS. Ng Th Bch H

Ths.BS. Trng L Vn Ngc

Ths.BS. Nguyn c Thng

BSCKI. Bi Th Hng Hoa

6

MC LC

Trang

Danh mc cc t vit tt 10

Chng 1. NHI KHOA I CNG 14

1.Cc thi k pht trin ca tr 14

Chng 2. HI SC CP CU CHNG C 21

1. Nhn bit v x tr cc du hiu e da chc nng sng tr em 21

2. Cp cu c bn 34

3. Tip cn chn on v x tr bnh nhi kh th 50

4. Ngng th ngng tim 56

5. Vn chuyn an ton bnh nhn tr em 67

6. Nguyn tc tip cn v x l ng c cp tr em 73

7. X tr vt thng do ngi v sc vt cn 77

8. X tr ong t tr em 80

9. Rn cn 85

10. Sc tim tr em 93

11. Sc gim th tch tun hon tr em 97

12. Sc phn v tr em 103

13. Sc nhim khun 110

14. Ri lon nc in gii 118

15. Ri lon kim toan tr em 127

16. Ri lon Can xi v Ma gi mu 138

17. Ri lon Natri v Kali mu 143

18. Nui dng tnh mch cho bnh nhn nng hi sc cp cu 150

19. Tng p lc ni s 156

20. Hn m 164

21. Co git 171

22. Vim phi lin quan n th my 176

23. Nhim khun huyt trn bnh nhn t Catheter mch mu 181

Chng 3. S SINH 185

1. H ng huyt s sinh 185

2. Tng ng huyt s sinh 191

3. Hi chng ht phn su 196

4. Tng p lc ng mch phi dai dng tr s sinh 201

5. Vim rut hoi t s sinh 207

6. Bnh phi mn tnh tr s sinh 213

7. Cn ng ng mch tr non 218

8. Vng da tng Bilirubine gin tip 223

7

9. Bnh mng trong tr non 230

10.Bnh no thiu oxy thiu mu cc b 233

11. Suy h hp s sinh 238

12. Dinh dng qua ng tiu ha cho tr sinh non, nh cn 244

13. D on, nh gi, iu tr v tin lng tr s sinh c nguy c cao 250

Chng 4. H HP 258

1. Vim phi do Virus 258

2. Vim phi do vi khun tr em 262

3. Vim phi khng in hnh tr em 266

4. Kh th thanh qun tr em 269

5. Trn kh mng phi 272

6. Vim tiu ph qun cp tr em 275

7. D vt ng th 279

8. Vim m mng phi 283

Chng 5. TIM MCH 286

1. Tn ti ng ng mch 286

2. Vim c tim do virus 290

3. Suy tim huyt 293

4. Vim m mng ngoi tim 297

5. Vim ni tm mc nhim trng 303

6. Chn on v iu tr bnh Kawasaki 311

Chng 6. TIU HA DINH DNG 316

1. Tiu chy cp 316

2. Tiu chy ko di 325

3. To bn 330

4. Nhim k sinh trng ng rut tr em 335

5. au bng chc nng 344

6. Bnh tro ngc d dy thc qun 349

7. Xut huyt tiu ha 354

8. Lot d dy t trng tr em 362

9. Phc iu tr vim lot d dy Helicobacte Pylori ti bnh vin 366

10. Bnh suy dinh dng do thiu Protein Nng lng 370

11. Bnh ci xng do thiu Vitamin D tr em 377

12. Bo ph tr em 384

Chng 7. GAN MT 393

1. Cc nguyn nhn gy vng da mt tr em 393

2. Teo ng mt bm sinh 399

3. Tip cn suy gan cp tr em 403

8

Chng 8. THN TIT NIU 408

1. Tip cn chn on Protein niu 408

2. Tip cn chn on i mu 412

3. Nhim trng ng tiu 417

4. Hi chng thn h tin pht tr em 424

5. Bnh Lupus h thng tr em 430

6. Suy thn cp 437

7. Bnh thn mn 444

Chng 9. THN KINH 449

1. Nhc u tr em 449

2. Co git do st 455

3. ng kinh tr em 459

4. Chy mu trong s tr em 467

Chng 10. TRUYN NHIM 473

1. Bnh Chn Tay Ming 473

2. Vim mng no m 482

3. Vim no 489

4. Bnh cm 496

5. Bnh si 500

6. Chn on, iu tr st xut huyt Dengue 505

7. St rt tr em 517

8. Nhim trng huyt 524

Chng 11. HUYT HC 534

1. Tip cn chn on thiu mu 534

2. Thiu mu thiu st 539

3. Bnh Thalassemia 543

4. iu tr suy ty xng mc phi 551

5. Chn on iu tr xut huyt gim tiu cu nguyn pht tr em 557

6. Hemophilia 560

7. Hi chng thc bo mu 564

8. Thiu mu tn huyt cp 572

9. Thiu mu tn huyt min dch 579

Chng 12. UNG BU 586

1. Bch cu cp dng Lympho 586

2. Tip cn chn on v x tr khi u c thng gp 595

3. U nguyn bo thn kinh 602

4. St gim bch cu ht 612

Chng 13. NI TIT CHUYN HA DI TRUYN Y HC 617

1. Suy thng thn tr em 617

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2. Tng sn thng thn bm sinh 621

3. H ng mu nng do cng Insulin bm sinh 626

4. Toan Xeton do i tho ng 632

5. i tho nht trung ng 638

6. Suy gip trng bm sinh 641

7. Long xng tr em 644

8. Dy th sm trung ng 648

9. Tip cn tr chm tng trng chiu cao v iu tr tr

chm tng trng do thiu ht hormon tng trng 654

10. Di truyn y hc v chm sc sc khe ban u 660

11. Tip cn chn on v nguyn tc iu tr cp cu cc ri lon

chuyn ha bm sinh 663

12. H ng mu trong cc RLCH bm sinh 668

13. Toan chuyn ha v toan Xeton

trong cc bnh ri lon chuyn ha bm sinh 672

14. Bnh thiu ht Enzym Beta - Ketothiolase 675

15. Tng Amoniac mu 678

16. Tng Lactate mu trong cc ri lon chuyn ha bm sinh 683

Chng 14. MIN DCH D NG KHP 685

1. Hen ph qun tr em 685

2. X tr cn hen ph qun cp tr em 694

3. Nhim trng ti din 700

4. D ng thc n tr em 710

5. D ng thuc 715

6. Vim khp t pht thiu nin 718

Chng 15. TM THN PHC HI CHC NNG 726

1. Ri lon tng hot ng gim ch tr em 726

2. Ri lon t k tr em 731

3. Ri lon TIC 739

4. Cc liu php tm l 743

5. Tm l bnh nhi nm vin 751

6. Ri lon gic ng tr em 756

7. Phc hi chc nng tr bi no 760

PH LC 769

1. T chc v trang b phng cp cu nhi 769

2. Nguyn tc s dng khng sinh trong nhi khoa 777

3. Khong tham chiu cc xt nghim huyt hc 784

4. Gi tr ha sinh bnh thng 790

10

T VIT TT

6MP 6- mercaptopurine

AFP Alpha feto Protein

ALL Bch cu cp dng Lympho

ALNS p lc ni s

ALOB p lc bng

BC Bch cu

BCN Bch cu non

BCTT Bch cu trung tnh

BP Bo ph

BPD Bronchopulmonary dysplasia

BUN Blood Urea Nitrogen

CADO French induction regimen consisting of

cyclophosphamide, adriamycin, vincristine, carboplatin

CCG Children Cancer Group

CLD Chronic lung disease

CMV Cytomegalo Virus

CO Cyclophosphamide, Vincristine

COJEC Rapid, platinum- containing induction schedule (CBDCA,

CDDP, CYC, VCR, VP16)

CPAP Continuous positive airway pressure

CRP C Reactive Protein

CTM Cng thc mu

BCN au bng chc nng

DD Dung dch

11

K ng kinh

M ng mch

MC ng mch ch

MP ng mch phi

T i tho ng

TDTE i tho ng tr em

EBV Epstein- Barr Virus

ELBW Extreme low birth weight

FAB French American British

GCSF Thuc kch bch cu

GIR Glucose influsion rate

HA Huyt p

Hb Hemoglobin

HC Hng cu

HCG Hormone Chorionique gonadotrope

HCTH Hi chng thn h

HI Hemophilus influenza

HPQ Hen ph qun

HSCC Hi sc cp cu

HSV Herpes simplex Virus

HVA Homovanillic acid

IDRF Image Defined Risk Factors

INPC International Neuroblastoma Pathology Classification

INRG International Neuroblastoma Risk Group

INSS International Neuroblastoma Staging System

12

IVC Inferior Vena Cava

LTS Life Threatening Symtoms

MBH M bnh hc

MIBG Meta- iodobenzylguanidine

MRD Bnh tn d ti thiu Minimal Residual disease

MRI Chp cng hng t

NBTK Nguyn bo thn kinh

NEC Necrotizing enterocolitis

NICU Neonate instensive care unit

NKBV Nhim khun bnh vin

NKHH Nhim khun h hp

NKM Nhim khun mu

NKQ Ni kh qun

NTT Nhim trng ng tiu

NTHH Nhim toan h hp

OMA Opsoclonus-myoclonus-ataxia

PCR Polymerase chain reaction

PDA Patent ductus arteriosus

PPHN Persistent pulmonary hypertension of the Newborn

PTNSLN Phu thut ni soi lng ngc

RA 13-cis Retinoic acid

RDS Respiratory dystress syndrom

RLCHBS Ri lon chuyn ha bm sinh

RNA Ribonucleic acid

RSV Respiratory Syncytial Virus

13

SDD Suy dinh dng

SGA Small for gestational age

SGC Suy gan cp

SGTTTH Sc gim th tch tun hon

SHH Suy h hp

SNK Sc nhim khun

SPV Sc phn v

TB Tim bp

TBS Tim bm sinh

TC Tiu cu

TM Tnh mch

TMC Tnh mch ch

TMTT Tnh mch trung tm

TNM Tumor Node Metastase H thng phn loi u hch, di

cn

TSB Total serum bilirubin

TVCH Thot v c honh

TVCHBS Thot v c honh bm sinh

TX Ty xng

VDM Vng da mt

VIP Vasoactive Intestinal Peptide

VMA Vanillyl mandelic acid

VMNM Vim mng no m

VP- Carbo Etoposide, Carboplatin

14

CHNG 1: NHI KHOA I CNG

CC THI K PHT TRIN CA TR

1. C IM CHUNG

Tr em khng phi l ngi ln thu nh m l mt c th ang ln ln v

pht trin. T lc th thai n tui trng thnh tr phi tri qua 2 qu trnh

chnh.

Qu trnh tng trng (pht trin v s): do s tng s lng v kch

thc t bo ca cc m.

Qu trnh trng thnh v cht (cu trc v chc nng hon chnh dn): do

s thay i v cu trc ca cc b phn dn n s thay i chc nng t bo.

Qu trnh ln ln v pht trin ca tr c tnh cht ton din c v th

cht, tm thn - vn ng v qua nhiu giai on. Mi giai on c nhng c

im v sinh l v bnh l ring.

T khi hnh thnh n khi trng thnh (15 - 20 tui) tr em tri qua 6

giai on pht trin: giai on bo thai, giai on s sinh; giai on nh nhi; giai

on rng sa; giai on thiu nin; giai on dy th. Cc giai on c c im

pht trin v nhu cu dinh dng khc nhau.

2. C IM CA TR QUA CC THI K

2.1. Thi k bo thai

Tnh t lc th thai n khi ra i (trung bnh 270 15 ngy) tnh t ngy

u tin ca k kinh cui cng. Thi k bo thai chia lm 3 giai on:

- Giai on th thai: ko di khong chng hai tun u ca thai k.

- Giai on pht trin phi: tun l th hai n th tm

- Giai on bo thai: t tun th chn n khi sinh

2.1.1. Giai on th thai v giai on pht trin phi:

- c im sinh l:

Giai on ca s hnh thnh v bit ho cc b phn. Phn ln cc giai

on pht trin cc c quan quan trng din ra trong 12 tun u. Nu c mt

yu t no lm nh hng n giai on pht trin, c bit thuc hay bc x th

cc d tt bm sinh s xy ra.

15

- c im bnh l:

3 thng u ca thai k l thi k hnh thnh thai nhi. Nu c iu g

can thip vo s pht trin ca cc c quan trong giai on ny th chng s

khng sa cha c sau ny

Trong thi k ny, nu m b nhim cc cht c (thuc hay ho cht),

hay b nhim virus nh nhim TORCH (Toxoplasmo, Rubeola, Cytomegalovirus,

Herpes simplex) th tr sinh ra d b d tt.

2.1.2. Giai on bo thai (tun l th chn n khi sinh)

- c im sinh l:

Sau khi phn ln cc c quan c hnh thnh, thi k bo thai dnh

ht hon ton cho s tng trng v hon chnh cc b phn. Rau thai hnh

thnh, m nui tr trc tip qua rau thai.

+ Tun th 13 14 thi k bo thai, gii tnh ca thai nhi c th c xc

nh.

+ Tun th 25 28: Tt c cc c quan b phn ca c th hon chnh v

y l giai on pht trin chiu di, cn nng ca thai nhi. T thng 3 n thng

th 6 tr di c 70% chiu di khi .

+ Tun th 37 41: l thi im thai nhi tng trng v trng lng c

th. Bo thai ln nhanh, c bit ba thng cui thai k t 700g qu II, tng mi

tun 200g trong qu III.

+ tr khe mnh thng minh th m khng c mc bnh v cn tng

10 -12 kg trong sut thi gian mang thai.

S tng cn ca m khi mang thai:

Thai k

Qu I

Qu II

Qu III

S cn m tng (kg)

0-2

3-4

5-6

B khe mnh l b khi sinh ra cn nng trung bnh l 3000gr (2500 -

3500gr), di trung bnh 50cm (48 -52cm) v khng c d tt bm sinh.

- c im bnh l: trong giai on ny, dinh dng ca thai nhi c

cung cp t ngi m qua rau thai. Nu ngi m khng dinh dng hay

tng cn km hoc m c vn v rau thai th tr sinh ra d c cn nng thp

lc sinh v t l t vong cao. non d xy ra trong 3 thng cui do rau thai

khng cn l hng ro vng chc bo v thai na.

16

2.2. Thi k s sinh: t lc ct rn cho n 4 tun l u.

2.2.1. c im sinh l

- S chuyn tip t i sng trong t cung sang ngoi t cung buc tr

phi c s thay i chc nng ca mt s c quan thch nghi vi cuc sng

mi nh hot ng ca b my h hp, b my tun hon. Trong cc c quan th

s thch nghi ca phi l quan trng nht. Nh th tt, h tun hon cng thch

nghi nhanh chng v h thn kinh nht l v no cng c kin ton.

- Ngay sau khi ra i, tr bt u th bng phi v vng tun hon chnh

thc thay cho tun hon rau thai. S thch nghi ca b my tiu ho, gan thn

bt u cng vi ba n u tin ca tr.

- B no tr cn non nt nn tr ng nhiu 20gi/ngy do v no trong

trng thi c ch. Tuy ng nhiu nhng tr bit git mnh khi c ting ng

mnh. Tr khng t ch c mi ng tc v c mt s phn ng t nhin ton

thn nh tng trng lc c nh.

- H tiu ha: nim mc ng tiu ha cha hon thin, cha c men

tiu bt. Thc n duy nht ca b l sa m hoc sa thay th. Tr bit b m

ngay t khi sinh ra. Tr khng thch ung nhng cht ng, chua, cay v rt

thch ngt v vy khng nn cho tr ung nc ng, sa b trc khi b m v

tr s ch sa m. Tr c kh nng ngi mi sa ca m qua nhn c m

v tm c v m.

- Cn nng: tr bnh thng, mi ngy trung bnh tr tng 15gram. Trung

bnh khi 1 thng tr nng t 3500 kg - 4500 kg. Chiu cao: tng khong 2cm.

2.2.2. c im bnh l

- V tr bt u thch nghi vi mi trng bn ngoi nn nhiu yu t c

th cn tr s thch nghi ca tr v gy t vong cao trong 24h u hoc tun u

tin sau sinh.

- Cc bnh l hay gp:

+ Sang chn sn khoa: gy ngt, xut huyt no, gy xng.

+ Glucose mu tr s sinh thp nn cn cho tr b sm sau khi sinh.

+ H thng min dch cn non yu nn tr d b nhim trng nh nhim

trng rn, phi, no, nhim trng huyt. Tuy vy nh c khng th t m chuyn

sang nn tr t b cc bnh nh si, bch hu...

- Cc bnh vng da tng bilirubin t do.

+ Do vy vic sn sc tt nht cho tr s sinh l chm sc tt trong giai

on trc sinh rt quan trng nhm hn ch vic kh, nhim trng nhm h

17

thp t vong s sinh. B m phi c khm thai nh k. V sinh cho tr, tr

sng trong iu kin sch s v sa m.

2.3. Thi k nh nhi (b m): t 2 thng n 12 thng tui

- c im sinh l: trong thi k ny tr ln rt nhanh.

+ Cn nng: trung bnh, 6 thng u tr nng gp i cn nng lc sinh

(khong 5-6kg) v n thng th 12 tr nng gp 3 (trung bnh t 9 kg - 10kg)

so vi lc .

+ Chiu cao: mi thng tng 2 cm. n 12 thng tr cao gp ri lc sinh

(trung bnh tr cao t 74cm - 78cm)

+ Vng u: tng 10cm (34+10= 44cm). T chc no tng nhanh t ti

75% so vi ngi ln (900g).

+ H tiu ha: hon thin dn v khi 4 thng bt u c kh nng tiu

ho c tinh bt v cc thc phm khc ngoi sa. Tr bt u mc rng

sa:

+ Cng thc tnh s rng sa = s thng 4.

Lp m di da pht trin mnh nn trng tr b bm do vy tr cn b

i hi nhu cu nng lng cao hn ngi ln trong khi chc nng ca b

my tiu ho cn yu, cc men tiu ho cn km nn d b ri lon tiu ho v

dn n suy dinh dng nu nui dng khng ng cch. V vy thc n tt

nht l sa m. Tr cn 120 - 130 calo/kg c th/ngy.

Cng vi s pht trin mnh v th cht, tr bt u c s pht trin tinh

thn, tr tu v vn ng.

+ Thn kinh: cng bt u pht trin, tr bt u nhn ra cc vt,

khun mt. Tp ci ni giao tip vi mi ngi xung quanh, 2 thng hng

chuyn, 3 thng ci thnh ting, chm ch nhn vo vt c mu , en, trng.

12 thng bit ch tay vo vt mnh a thch. Phn bit c li khen v cm

on.

+ Vn ng: tr tp b, ng, i. 3 thng bit ly, 8 thng bit b, 9 thng

bit hoan h, 12 thng bit i.

+ Ngn ng: 9 thng bt u pht m b, ba, m.

12 thng pht m c 2 m.

2.3.1. c im bnh l: sau 6 thng tr d mc cc bnh nhim trng.

Tr d b tiu chy cp, tiu chy ko di, nn, chn n do chc nng ca

h tiu ho cha hon chnh nht l tr khng b m. tr c nui bng sa

m cc ri lon d dy-rut t gp v nh hn tr nui nhn to.

18

- Tc pht trin nhanh cng h tiu ho km nn tr d b suy dinh

dng, thiu vitamin, thiu mu. Ngoi ra cc thc n nhn to thng thiu cc

vi cht cn thit, cc vitamin v t l phn b cc cht khng hp l.

- Trung tm iu nhit v da ca tr cng cha pht trin y , qu trnh

c ch v hng phn vn c xu hng lan to nn cc yu t gy bnh u c

th phn ng ton thn do tr d b h thn nhit hoc st cao co git, phn

ng no, mng no.

- Trong 6 thng u tr t b cc bnh nhim trng cp nh si, bch hu...

do khng th t m (IgG) truyn sang qua rau cn tn ti c th tr.

- Cng v sau, min dch t m truyn sang gim dn, trong lc h

thng min dch ca tr hy cn non yu nn tr d mc cc bnh ly nh vim

phi, vim mng no, bch hu, si. Tr hay b chn thng do ng v bt u

tp i.

2.4. Thi k rng sa: (Thi k trc khi i hc)

T 1n 6 tui. C th chia lm 2 thi k nh: Tui nh tr: 1 - 3 tui, tui

mu gio: 4 - 6 tui.

2.4.1. c im sinh l

Trong thi k ny tr tip tc ln v pht trin nhng tc ln chm hn

giai on trc. Chc nng vn ng pht trin nhanh, tr bt u i mt mnh

ri chy, tp v, vit, tr t xc thc n, ra tay, ra mt Tn hiu th hai,

ngn ng pht trin. Tr bt u i hc. Tr la tui mu gio c c im

hiu ng. Cc c pht trin mnh nhng trng lc c dui nh hn c gp

nn tr khng ngi lu c.

- Cn nng: mi thng tng t 100gram - 150gram. T l m trong c th

thp nht so vi cc la tui nn nhn tr c v gy m.

- Chiu cao: mi nm tng 5cm chiu cao. 6 tui tr cao t 105cm -

115 cm.

Cng thc tnh chiu cao cho tr > 1 tui:

X (cm) = 75 + 5 (N -1)

(X= chiu cao; N= s tui tnh theo nm)

Vng u bng ngi ln (55cm), t chc no trng thnh bng 100%

ngi ln.

- H tiu ha: hon thin, tr mc 8 rng hm

- Hot ng: tr t m, hot ng nhiu, ham hc hi, thch t lm vic.

C nhng hot ng giao tip, ham chi hn n.

19

2.4.2. c im bnh l

Xu hng bnh t lan to. la tui ny tr cng rt d b cc ri lon

tiu ho, ci xng, cc bnh v th tng. Trong thi k ny min dch th ng

t m chuyn sang gim nhiu nn tr hay mc cc bnh nh cm, ho g, bch

hu, thng b bnh ly do i sng tp th.

Xut hin cc bnh c tnh cht d ng: hen ph qun, m ay cp, vim

cu thn cp. Tr hot ng nhiu nn hay b cc tai nn, chn thng, ng c,

bng...

2.5.Giai on thiu nin: tui hc ng.

C 2 thi k: tui hc sinh nh: 7 -

20

- Chiu cao cng pht trin nhanh hn trong nhng nm u, cn tranh

th giai on ny tng chiu cao ca tr. Tng t 5-8 cm/nm vi n v 5,5-9

cm/nm vi nam sau chiu cao tng chm dn. Chiu cao ca n dng li khi

19-21 tui v nam l 20-25 tui.

Cn nng p dng cng thc:

X (kg) = 21 + 4 (N-10)

(X= cn nng; N= s tui tnh theo nm)

2.6.2. c im bnh l

- Trong thi k ny thng xy ra s mt n nh trong cc chc nng ca

h giao cm - ni tit, nn thng thy nhng ri lon chc nng ca nhiu c

quan nh hay hi hp, tng huyt p, nhng ri lon v thn kinh: tnh tnh thay

i, d lc quan nhng cng d bi quan hay c nhng suy ngh bng bt...

- V bnh tt: giai on ny tr thng t bnh tt hn c, tuy nhin t t

v cc bnh tm thn li xut hin nhiu .

Tm li:

- S ln ln v pht trin ca tr em tri qua 2 giai on c bn bao gm 6

thi k. Ranh gii gia cc thi k ny khng r rng m thng xen k nhau.

Ngoi ra cn c mt s yu t tc ng khng nh n qu trnh ln ln v pht

trin ca tr hoc nh hng n dung mo bnh tt ca tr nh ngoi cnh, mi

trng sng ca tr (yu t ngoi sinh).

- Mi mt la tui c c im sinh l v bnh l ring, nu p dng ch

chm sc v nui dng ng, tr s c mt sc kho tt. Tr cn c s chm

sc tt ca gia nh, x hi v cch nui dng ng. xc nh tr cht

dinh dng hay cha cch tt nht l theo di cn nng v khm sc kho ca

tr mi thng can thip kp thi, trnh hu qu lu di.

- Do nhim v ca nhng cn b Nhi khoa l phi nm vng nhng c

im ca cc thi k trn, to iu kin m bo cho s ln ln v pht trin

ca tr c tt.

TI LIU THAM KHO

1.Ti liu ging dy ca b mn nhi Hu (gio trnh ca b mn nhi Hu)

2. Bi ging Nhi Khoa ca B Mn Nhi- Trng i hc y khoa TP HCM

(2000).

3. Bi ging Nhi Khoa tp 1 B Mn Nhi- i hc Y Khoa H Ni (2006).

21

CHNG 2: HI SC CP CU CHNG C

NHN BIT V X TR CC DU HIU E DA

CHC NNG SNG TR EM

T vong bnh vin thng xy ra trong vng 24 gi u nhp vin.

Phn ln cc trng hp t vong ny u c th ngn nga c nu tr b bnh

nng c pht hin sm v x tr ngay sau khi n bnh vin .

Vic nhn bit cc du hiu e da chc nng sng l mt quy trnh sng

lc nhanh tr bnh, c th xp tr vo cc nhm sau:

- Tr c du hiu cp cu cn iu tr cp cu ngay lp tc.

- Tr c du hiu cn u tin cn c khm u tin trong lc i, phi

c nh gi v c iu tr khng chm tr.

- Tr khng cp cu l nhng tr khng nng, c cc du hiu khng

nm trong 2 nhm trn.

1.CC DU HIU E DA TNH MNG bao gm:

* Tc nghn ng th * Suy h hp nng

* Tm ti trung tm * Cc du hiu sc

* Hn m * Co git

Tr c du hiu cp cu cn iu tr ngay lp tc ngn nga t vong.

Tr c du hiu cn u tin l nhng tr c nguy c t vong cao. Nhng

tr ny cn c nh gi ngay, khng chm tr.

2.NHN BIT DU HIU E DA TNH MNG

Vic nhn bit cc du hiu ny phi c thc hin ni tip nhn bnh

nhn trong bnh vin, trc khi lm bt k th tc hnh chnh no nh th tc

ng k khm HOC ngay khi bnh nhn nhp khoa cp cu. Do phi t

chc mt trnh t bnh nhn khi n vin tun theo. Tr phi c phn loi

trc khi b m ngi vo phng i. Cn c mt y t nh gi nhanh tnh trng

tng tr trc khi cn v trc khi lm th tc ng k khm

2.1. nh gi ban u ng th v th

Nhn bit du hiu suy h hp

22

Th gng sc

Khi mc th gng sc tng ln l biu hin nng ca cc bnh h hp.

Cn nh gi cc ch s sau y:

Tn s th

Cn s dng nhp th nh l cng c nhn nh s thay i lm sng

tt ln hay xu i.

Khi c biu hin ri lon nhp th, th nhanh tng thng kh do bnh

ca phi hoc c cn tr ng th, hoc toan mu. Nhp th chm th hin suy

yu sau gng sc, tng p lc ni s hoc giai on gn cui.

Bng 1.Nhp th bnh thng ca bnh nhn theo tui

Tui Nhp th (ln/pht)

12

30 40

25 35

25 30

20 25

15 20

Rt lm lng ngc

Co rt c lin sn, h sn v cc hm c u th hin th gng sc.

Mc rt lm th hin mc kh th. Khi tr th gng sc lu v suy yu

i, th du hiu rt lm lng ngc cng mt i.

Ting n th ht vo, th ra

Ting th rt th ht vo (stridor) l du hiu ca tc nghn ti vng hu

v thanh qun. Kh kh gp nhng tr c tc nghn ng h hp di v

thng nghe thy th th ra.Th th ra ko di cng th hin c tc hp ng

th di. Mc to nh ca ting n khng tng ng vi nng ca bnh.

Th rn

y l du hiu rt nng ca ng th v c trng tr nh b vim

phi hoc ph phi cp. Cng c th gp du hiu ny nhng tr c tng p

lc ni s, chng bng hoc vim phc mc.

S dng c h hp ph

Cng nh ngi ln, khi cn th gng sc nhiu hn c th cn s dng

n c c n chm.

23

Php phng cnh mi

Du hiu php phng cnh mi hay gp tr nh c suy th

Th ht ra

y l du hiu khi thiu oxy nng v c th l du hiu ca giai on

cui.

Hu qu ca suy th ln cc c quan khc

Nhp tim

Thiu oxy dn n nhp tim nhanh tr ln v tr nh. Tr quy khc v

st cng lm tng nhp tim, lm cho du hiu ny khng c hiu. Thiu oxy

mu nng hoc ko di s lm nhp tim chm v l giai on cui.

Mu sc da

Thiu oxy mu (do gii phng catecholamine) gy co mch v da nht.

Tm ti l du hiu nng biu hin giai on cui ca thiu xy mu. Cn phn

bit vi tm do bnh tim.

Tri gic

Tr c thiu oxy hoc tng CO2 mu s kch thch vt v hoc li b. Khi

bnh nng ln trng thi li b s r rt hn v n mc hn m. Nhng du hiu

ny c bit c gi tr nhng thng kh thy tr nh.

nh gi li

Ch theo di nhp th, mc rt lm, vv... l c nhng thng tin quan

trng, nhng cha . Cn thng xuyn nh gi li pht hin xu hng

din tin lm sng ca bnh nhn.

2.2.Bc u nh gi tun hon (Circulation)

Nhn bit nguy c suy tun hon

Tnh trng tim mch

Nhp tim

Nhp tim c th tng ln giai on u ca sc do s gii phng

catecholamin v b li mt dch. Nhp tim, c bit l tr nh, c th rt cao

(n 220 nhp/pht).

Bng 2. Nhp tim v huyt p tm thu theo tui

Tui (nm) Nhp tim (ln/pht) HA tm thu (mmHg)

12

110 160

100 - 150

95 140

80 120

60 - 100

70 90

80 - 95

80 100

90 110

100 120

24

Mch chm bt thng, nhp tim chm, l khi nhp tim t hn 60 ln/pht

hoc gim nhp tim nhanh chng cng vi biu hin suy gim cp mu. y l

du hiu nng giai on cui.

ny ca mch

C th trong sc nng, huyt p vn duy tr c, du hiu ch im l cn

so snh ny ca mch ngoi bin v trung tm. Khi khng bt c mch

ngoi bin v mch trung tm bt yu l du hiu ca sc, v c tt huyt p.

Mch ny mnh c th gp trong c khi tng th tch tun hon (v d, trong

nhim khun huyt), cu ni ng tnh mch trung tm (v d, cn ng ng

mch) hoc khi c tng CO2 mu.

Du hiu y mao mch tr li (refill)

Khi thi gian y mao mch tr li ko di hn th hin gim cp mu

ngoi bin. Khng nn s dng ring l cc du hiu ny nh gi sc hoc

nh gi mc p ng vi iu tr.

Huyt p ng mch

Bng 3. Huyt p tm thu theo tui

H huyt p l du hiu mun ca giai on cui ca suy tun hon. Khi

c h huyt p l sp c nguy c ngng tim. Tng huyt p c th l nguyn

nhn hoc l hu qu ca hn m v tng p lc ni s.

nh hng ca suy tun hon ln cc c quan khc

C quan h hp:

Nhp th nhanh, su nhng khng c co ko lng ngc, l hu qu ca

toan mu do suy tun hon gy ra.

Da

Da m, lnh, nht nht vng ngoi bin l biu hin ca gim cp mu.

Khu vc da lnh c th gn vng trung tm hn nu suy tun hon tip tc

nng ln.

Tui (nm) Huyt p tm thu (mmHg)

12

70 90

80 95

80 - 100

90 110

100 120

25

Tri gic

Tr c th kch thch vt v hoc l m, li b n hn m nu c suy tun

hon. y l hu qu ca gim cp mu no.

Nc tiu

Lng nc tiu t hn 1 ml/kg/gi tr v t hn 2 ml/kg/gi tr nh

nhi l du hiu gim cp mu thn trong sc. Cn khai thc nu c thiu niu

hoc v niu trong bnh s.

Suy tim

Nhng du hiu sau s gi suy th do nguyn nhn tim mch:

Tm, khng p ng vi oxy

Nhp tim nhanh khng tng ng vi mc kh th

Gan to, tnh mch c ni

Ting thi tm thu/ nhp nga phi, khng bt c mch i

2.3. nh gi ban u chc nng thn kinh

Nhn bit nguy c tn thng thn kinh trung ng

Thiu oxy t chc hoc sc u c th gy ri lon thc. V vy, bt c

ri lon no xy ra khi nh gi theo ABC cng phi c xem xt trc khi kt

lun ri lon thc l do nguyn nhn thn kinh.

Chc nng thn kinh

Mc tri gic

C th nh gi nhanh thc ca bnh nhn mt trong 4 mc sau y:

A: Tnh to (ALERT)

V: p ng vi li ni (VOICE)

P: p ng vi au (PAIN)

U: Khng p ng (UNRESPONSIVE)

T th

C nhiu tr mc nhng bnh nng cc c quan c biu hin gim

trng lc c. Nhng t th co cng nh bc v (tay co, chn dui) hoc mt

no (tay dui, chn dui) l biu hin tn thng no tr em. Du hiu c cng

v thp phng tr nh gi v bnh vim mng no.

26

ng t

Nhiu loi thuc v tn thng no c th lm thay i kch thc v

phn x ca ng t. Nhng du hiu ng t quan trng cn tm l: gin ng

t, ng t khng phn x, hoc ng t 2 bn khng cn xng l nhng du

hiu tn thng no nng.

nh hng n h h hp do tn thng thn kinh trung ng

C nhng kiu th bt thng do tng p lc ni s. Nhng kiu th ny

c th thay i t mc tng thng kh cho n kiu th Cheyne Stokes hoc

ngng th. Nhng kiu th bt thng ny bnh nhn hn m chng t c tn

thng no gia v no sau.

nh hng n h tun hon do tn thng thn kinh trung ng

Khi c du hiu chn p hnh no do tt kt thng km theo tng huyt

p v nhp tim chm (p ng kiu Cushing). y l du hiu ca giai on

cui.

2.4. Khm ton thn

Nhit

Khi tr c st thng gi n nguyn nhn bnh l do nhim trng,

nhng cng c th st l do co git hoc rt run ko di.

Pht ban:

Khm ton thn tr c th thy cc dng pht ban, t dng mn gp trong

phn ng d ng; hoc ban xut huyt, t mu trong nhim khun huyt hoc tr

b xm hi, hoc m ay ln c phng nc gp trong phn ng d ng v mt

s dng nhim trng.

3. CCH TIP CN MT TR B BNH NNG

X tr cp cu mt tr cn phi nh gi nhanh v can thip kp thi. Cc

bc tip cn mt tr b bnh nng gm:

1. nh gi bc u

2. Hi sc

3. nh gi bc hai v tm nhng vn mu cht

4. X tr cp cu

5. n nh v vn chuyn bnh nhn n n v iu tr

3.1. nh gi bc u v hi sc

ng th (Airway)

27

nh gi ban u: nh gi s thng thong ng th theo trnh t:

Nhn di ng lng ngc v bng

Nghe thng kh phi

Cm nhn lung kh th ch c hiu qu khi bnh nhn th t nhin.

Nu tr ni c hoc khc c chng t ng th thng thong, h

hp m bo.

Nu tr t th, ch n cc du hiu khc c th gi tc ng h hp

trn nh:

Ting th rt

Cc du hiu co ko

Nu khng c bng chng chc chn v s lu thng ca ng th th

lm k thut n hm v nng cm, sau nh gi li. Nu ng th vn cha

lu thng th c th tin hnh m ming bnh nhn v thi ngt.

Hi sc

Bng cc k thut: nhn, nghe v cm nhn m thy ng th khng

thng thong th c th m thng ng th bng:

K thut nng cm v n hm

iu chnh t th bnh nhn m bo s thng thong

C th t ni kh qun (NKQ) nu thy cn thit.

H hp (Breathing)

nh gi ban u

ng th thng thong cha chc thng kh y . Thng kh ch

t c hiu qu khi c s phi hp ca trung tm h hp, phi, c honh v

cc c lng ngc.

Hi sc

S dng oxy lu lng cao (15lt/pht) cho nhng bnh nhn c ri lon

h hp hoc thiu oxy t chc. Nhng bnh nhn c suy h hp cn c thng

kh vi oxy qua mt n c van v ti hoc t ng NKQ v cho th p lc dng

ngt qung.

Tun hon (Circulation)

nh gi ban u

Cc bc nh gi tun hon c m t.

28

Hi sc

Tt c cc trng hp suy tun hon (sc) nn c cho th oxy qua mt

n, hoc qua ng NKQ (nu cn phi t ng kim sot ng th).

S dng ng truyn tnh mch hoc ng truyn trong xng

truyn ngay dung dch in gii hoc dung dch keo vi lng dch l 20ml/kg

v ly cc mu mu xt nghim ngay thi im ny.

nh gi chc nng thn kinh

nh gi ban u

Thiu oxy t chc hoc sc u c th gy ri lon thc. V vy cn

nh gi theo ABC trc khi xem xt cc ri lon thc l do nguyn nhn thn

kinh. Thm na, cn lm test ng mu trc bt c tr no c suy gim tri

gic hoc co git.

Hi sc

Nu bnh nhn c ri lon thc mc P hoc U (ch p ng vi

au hoc khng p ng), phi cn nhc t ng NKQ kim sot ng th.

iu tr h ng huyt bng dung dch glucoza 10% 2ml/kg. Trc khi truyn

ng, ly mu xt nghim ng v cc xt nghim.

3.2. nh gi bc hai v iu tr cp cu

Ch c thc hin sau khi tin hnh nh gi ban u v iu tr cc

du hiu e do tnh mng. nh gi bc hai gm hi bnh s, thm khm lm

sng v lm cc xt nghim c hiu. Do thi gian c hn nn vic tip cn phi

tp trung vo nhng vn thit yu. Khi nh gi bc hai xong, bc s phi

hiu hn v bnh ca tr v c chn on phn bit. Vic iu tr cp cu giai

on ny l ph hp, c iu tr tnh trng chuyn bit (nh hen ph qun) ln

iu tr hi chng (tng p lc ni s).

H hp nh gi bc hai

Cc triu chng h hp thng gp:

Triu chng

Kh th

S mi

Ho

Th n o (th rn, th rt, kh kh...)

Khn ting

Khng ung c

au bng

Du hiu

Nhp th nhanh

Co rt lng ngc

Th rn

Cnh mi php phng

Th rt

Kh kh

Lp bp thnh ngc

29

Tm ti

Co rt lng ngc

au ngc

Ngng th

Khng n c

Nhp th nhim toan

Kh qun b y lch

Ting g bt thng

Nghe ting ran n

Xt nghim

o lu lng nh nu nghi ng hen, chp XQ phi, kh mu ng mch,

bo ho oxy.

iu tr cp cu

Nu nghe thy ting lc sc do ng th c nhiu dch th phi ht m

di.

Khi c th rt kt hp vi ho ng ng v kh th nng th ngh n vim

tc thanh qun nng, iu tr bng kh dung adrenalin 1 5ml v oxy.

Nu c ting rt nh v tr mt th xem c vim np thanh mn khng, tuy

nhin bnh ny him gp. C th lin h bc s gy m tr gip. Khng nn

c cc can thip th bo vo ng th.

Nu bnh ca tr khi pht t ngt v c tin s sc r th ngh n d

vt thanh qun. Lm cc bin php tng d vt ra ngoi khng thnh cng th

phi soi thanh qun gp d vt. Khng c can thip th bo vo ng th.

Khi cn, lin h vi bc s gy m m kh qun gp.

Ting th rt xy ra sau khi bnh nhn tim hoc n phi d nguyn th

ngh n phn v. Cho adrenalin 1 10g/kg, tim bp.

Nhng tr c tin s hen ph qun, th kh kh, suy h hp nng, lu

lng nh gim hoc thiu oxy t chc th phi c iu tr bng kh dung cc

thuc ch vn 2 v ipratropium vi O2.

i vi tr b nhim toan, cn ly mu lm kh mu v ng mu. iu

tr nhim toan do i ng bng huyt thanh mn 9 v insulin

30

Tun hon (Circulation): nh gi bc hai

Cc du hiu lm sng thng gp:

Triu chng

Kh th

St

Nhp tim nhanh

n ung kh

Tm ti

Xanh xao

Gim trng lc c

Tnh trng ng g

Mt dch

Thiu niu

Du hiu

Nhp tim nhanh

Nhp tim chm

Ri lon nhp v bin mch

Mu sc v ti mu da bt thng

Gim HA

Tng HA

Ri lon nhp th v bin th

Gan to

Phi c ran

Cc ting thi tim

Ph ngoi bin

Tnh mch c ni

Cc xt nghim

Ur, in gii , kh mu, XQ phi, in tm , cng thc mu, cy mu.

iu tr cp cu

Bolus dch nu bnh nhn sc, khng p ng vi ln bm dch th nht.

Cn nhc dng thuc vn mch v t NKQ nu phi bolus dch ln 3.

Cn nhc vic s dng khng sinh TM trong trng hp tr sc nu

khng c du hiu mt nc v c th l nhim khun mu.

Nu bnh nhn c ri lon nhp tim th dng phc lon nhp thch hp.

Nu sc phn v th dng adrenalin TB liu 10mcg/kg v theo phc sc

phn v.

31

Thn kinh (disability)

nh gi bc hai: Cc triu chng thng gp

iu tr cp cu

Nu co git ko di, dng phc x tr trng thi ng kinh

Nu c bng chng ca tng p lc ni s nh mt thc cp tnh, t th

bt thng hoc phn x vn ng nhn cu bt thng, tr cn c t ng

NKQ v thng kh nhn to. Cn nhc dng manitol 0,5g/kg tnh mch.

Nu tri gic gim hoc co git, cn ngh n vim mng no hoc vim

no v cho cefotaxim/acyclovir.

Nu tr l m v th yu, cn kim tra ng mu, kh mu, nh lng

salicylate trong mu. iu tr nhim toan do i ng bng huyt thanh mn

9 v insulin.

Nu tr hn m, ng t co nh th ngh n ng c opiate, c th dng

th naloxone.

Triu chng

au u

Co git

Thay i hnh vi

Ri lon thc

Gim vn ng

Ri lon th gic

St

Du hiu

Ri lon thc

Co git

Kch thc ng t v phn x nh sng

thay i

T th bt thng

Phn x mt no bt thng

Cc du hiu mng no

Ph gai th v xut huyt vng mc

Phn x gn xng thay i

Tng huyt p

Mch chm

Xt nghim

Ur, G, ng mu, cy mu (c chn lc)

32

Khm ton thn (exposure)

nh gi bc hai

Cc triu chng thng gp

Triu chng

Ban d ng

Sng mi, li

St

Du hiu

Ban hoi t

My ay

Ph mch

iu tr cp cu

Nu tr c triu chng ri lon tun hon v thn kinh, c ban xut huyt

th gi c nhim khun huyt hoc vim mng no m, iu tr bng cefotaxim

v cy mu.

Nu tr c triu chng h hp, tun hon, c ban m ay hoc ph mch

th gi c sc phn v, iu tr bng epinephrin 10 mcg/kg tim bp.

Tiu ho

Cp cu tiu ho thng gp l sc do mt dch. iu ny d nhn thy

khi nh gi ban u v tun hon hoc nh gi bc hai v tim mch.V cng

cn tm loi tr cc du hiu ngoi khoa.

Bnh s b sung

Mi trng sng v s pht trin ca tr

c bit l i vi tr nh v tr nh nhi, hiu bit v qu trnh pht trin,

tim chng v hon cnh gia nh ca tr rt hu ch. Ngi nh c th nh cc

bnh mc ca tr.

Thuc v d ng

Nu nghi ng tr b ng c th phi quan tm n tin s dng thuc

nh hoc iu tr trc .

TM TT

Cc bc nhn bit cc du hiu e da chc nng sng cho php thy

thuc chn on v iu tr bnh ca tr trong nhng gi u mt cch thch

hp. nh gi ban u v hi sc nhm duy tr chc nng sng c bn, nh gi

bc hai v iu tr cp cu cho php iu tr c hiu hn. Giai on iu tr

xc nh i hi ngi thy thuc phi lm tng bc, c h thng trnh b

st nhng du hiu thay i trn lm sng.

33

TI LIU THAM KHO

1. Simon Nadal, Nirajan, Suchitra R (2008) Recognition and intial

Management of Shock Roger textbook of PICU 4th edition William & Willkins,

p 372- 380.

2. Advanced Paediatric Life Support: The Practical Approach, Chapter 7

The structured approach to the seriously ill childFifth Edition Australia and

New Zealand 2012. , p 207-218

3. Bebra L, Weinner (2008) Respiratory Distress Texbook of Pediatric

Emergency Medecine, 4th

p 553-564.

34

CP CU C BN

1. GII THIU

Cp cu c bn trong nhi khoa l vic p dng chnh xc cc k thut cp

cu c bn theo kch thc ca tr. Ranh gii gia cc la tui c p dng:

tr nh nhi (di 1 tui) v tr nh (di 8 tui).

tr em, nguyn nhn chnh gy suy h hp - tun hon l do thiu oxy.

V vy, vic cung cp oxy cho tr cn cn thit hn c vic chng rung tht. y

l iu khc bit chnh so vi phc cp cu p dng cho ngi ln.

2. NH GI V IU TR

Sau khi tr c tip cn an ton, nh gi mc tri gic bng

phng php n gin, tin hnh nh gi v x tr tr theo trnh t A - B - C.

Trnh t cp cu c bn chung cho tr b ngng th - ngng tim c tm tt

trong hnh.1.

Ch : Hng dn ny dnh cho mt hoc nhiu ngi cp cu.

35

S cp cu c bn

D Nguy him?

R Hi : Chu c b sao khng

S Gi ngi h tr

A M thng ng th

B

Nhp th bnh thng ?

Thi ngt 2 ln

C

Kim tra mch

Khng qu 10 giy

Bt u CPR

15 p tim : 2 ln thi ngt

D

Kt ni my shock in

Chc chn gip ang n

Tip tc CPR cho n khi tr c p ng

Hoc nhp th bnh thng

Thng 4 2011, Hip hi hi sc c v New Zealand dnh cho o

to cc nhn vin y t.

Xem s gc ti www.resus.org.au

36

Tip cn ban u: Danger, Responsive, Send for help (DRS)

Ngi cp cu khng c mnh tr thnh nn nhn th hai,

a tr phi c thot khi s nguy him cng nhanh cng tt. Nhng

vic ny phi c thc hin trc khi tin hnh nh gi ng th.

Trong trng hp c mt ngi cp cu, nn gi s h tr ngay khi pht

hin nn nhn khng p ng. Cc bc tip cn c tm tt trong hnh 2.

D Nguy him?

R Hi : Chu c b sao khng

S Gi ngi h tr

Hnh 2: Tip cn ban u

Khi c trn 2 ngi tin hnh cp cu th mt ngi s lm cp cu c

bn trong khi ngi th hai gi cp cu.

Tr s sinh hoc tr nh, nhn vin cu h c th b a tr ra ni in

thoi v vn tip tc lm cp cu c bn trn ng.

Gi in thoi trc

Trong mt vi trng hp, trnh t trn b o ngc nh trong ngng tim

do ri lon nhp tim th tin hnh sc in sm c th cu c tnh mng

tr. Trng hp ny, nu c 2 ngi 1 ngi cp cu c bn, 1 ngi gi cp

cu. Nu ch c mt nhn vin th nn tin hnh gi trung tm cp cu trc

v tin hnh cp cu c bn ngay sau .

Khi ng thit b y t trc khi tin hnh cp cu c bn khi ch c

mt ngi cu h trong trng hp:

37

Chng kin mt ngi t ngt ngt xu m khng c du hiu bo trc

g.

Chng kin mt tr t ngt ngt xu m tr ny c bt thng v tim

v khng c nghi ng nguyn nhn do h hp hay tun hon.

Chu c b sao khng?

Hi tr: Chu c b sao khng? v kch thch tr nh gi u v lay tay

tr. Nhng tr nh nhi v tr nh, nu v qu s m khng tr li c, vn c

th p ng bng cch m mt hoc ku ln nhng ting nh.

Hnh 3: Nng cm tr nh nhi: t th trung gian

Hnh 4: Nng cm tr ln

38

ng th (Airway - A)

M thng ng th, tr c th hi phc m khng cn can thip g

thm. Nu tr c li tt v pha sau gy tc nghn hu hng, phi m thng

ng th bng th thut nga u v nng cm. Tr nh nhi, t c t th

trung gian, tr ln th t c hi ng ra sau. Tr t tm c mt t th thch

hp duy tr s thng thong ng th. V vy, khng nn p tr phi

t th khng thoi mi.

nh gi s thng thong ng th bng cch:

NHN di ng ca lng ngc v bng

NGHE ting th

CM NHN hi th

Ngi cp cu nghing u trn mt tr, tai trn mi tr, m trn ming

tr v nhn dc theo lng ngc tr trong vng 10 giy.

Trong trng hp khng thc hin c th thut ny hoc c chng ch

nh do nghi ng chn thng ct sng c, c th dng th thut n hm. Dng

2 - 3 ngn tay t di gc hm 2 bn v y hm ra pha trc. Phng php

ny d thc hin hn nu khuu tay ngi cp cu t trn vng mt phng m

tr ang nm. u tr c th nghing nh v mt bn.

Hnh 5: n hm tr nh nhi v tr ln

39

nh gi s thnh cng hay tht bi ca bin php can thip bng cch

dng k NNG NHN, NGHE v CM NHN.

Ch : trong trng hp c chn thng, bin php an ton nht l n

hm nhng khng nga u.

Th (B)

Nu p dng cc bin php m thng ng th m tr vn khng th

li trong vng 10 giy th nn bt u thi ngt.

Cn thi ngt 2 ln

Trong khi gi thng thong ng th, tin hnh thi ngt theo phng

php ming ming cho tr ln hoc c ming v mi cho tr nh.

Hnh 6: Thi ngt ming - ming v mi tr nh nhi

Thi chm 1-1.5 giy v lm cho lng ngc di ng nh mc bnh

thng, nu thi qu mnh s gy bng chng v tng nguy c tro ngc

dch d dy vo phi. Gia 2 ln thi, ngi cp cu ht th cung cp c

nhiu oxy cho nn nhn hn.

Do cc tr em c kch thc ln nh khc nhau nn ch c th a ra

mt hng dn chung lin quan n th tch v p lc thi ngt nh sau :

Ch dn chung v thi ngt

Lng ngc di ng theo nhp thi ngt.

p lc thi ngt c th cao hn bnh thng v ng th nh.

Nhp thi ngt chm vi p lc thp nht mc c th c lm

gim chng bng (do hi i thng vo d dy).

n nh vo sn gip lm gim kh vo d dy.

40

Nu lng ngc vn khng n thng do khng p dng chnh xc cc k

thut m thng ng th. Do , t li t th u tr v tip tc thc hin thi

ngt. Nu vn khng c kt qu th nn n hm. Mt ngi cp cu c th va

n hm, va thi ngt. Nu c hai ngi cp cu mt ngi s m thng ng

th, mt ngi tin hnh thi ngt. Thc hin 2 ln thi ngt, ch xem tr c

ho hay c p ng li hnh ng ca bn hay khng. S p ng l mt phn

ca nh gi du hiu sinh tn c m t di.

Khi t li t th u tr v n hm m vn khng c kt qu th phi

nghi ng c d vt lm tc nghn ng th. Cn tin hnh cc phng php

ph hp khc.

Tun hon (C)

Ngay khi ang tin hnh phng php thi ngt phi ch n tun

hon.

nh gi:

Tun hon khng y c xc nh khi khng c mch trong vng 10

giy hoc khi c mch nhng mch chm. ngi ln v tr em c th bt

mch cnh nh gi, tuy nhin bt mch trong vng 10 giy l vn kh.

V vy khi vng mt ca cc du hiu sinh tn (c ng, ho hoc nhp th bnh

thng) l ch nh u tin ca p tim.

tr nh c th bt mch cnh hoc mch bn cn tr nh nhi, do c

ngn v bo nn bt ng mch cnh tay v ng mch i (hnh 7).

Hnh 7. Bt mch cnh tay

41

Bt u p tim ngoi lng ngc khi:

Khng c du hiu ca s sng.

Khng c mch.

Mch chm (t hn 60 nhp/pht vi du hiu ti mu km)

Trong trng hp khng c du hiu ca s sng p tim c th c tin

hnh ngay, nu trong trng hp bn khng chc chn l nhp tim trn 60

nhp/pht trong 10 giy th vic p tim khng cn thit cng khng gy tn

thng.

Nu c mch vi tn s v du hiu ti mu tt m tr vn ngng th

th phi tip tc thi ngt cho n khi tr th li.

p tim ngoi lng ngc

t tr nm nga trn mt phng cng t c kt qu tt nht. tr

nh nhi c th s dng bn tay ngi cp cu to mt phng ny.

Do kch thc tr khc nhau nn thng thng tr nh nhi (8 tui) c th s dng k thut dng cho ngi

ln v iu chnh cho ph hp vi kch thc ca tr. p tim su xung khong

1/3 b dy lng ngc ca tr.

V tr p tim thng nht cho mi la tui l : Mt phn hai di xng

c

Tr nh nhi

Vi tr nh nhi: p tim c hiu qu hn khi s dng k thut 2 tay m

vng quanh ngc (hnh 8). Phng php ny ch c th p dng khi c 2 ngi

cp cu v cn phi c thi gian t li t th m thng ng th.

Hnh 8 : p tim tr nh nhi - k thut 2 tay vng quanh ngc

42

Mt ngi cp cu c th s dng phng php 2 ngn tay. Mt tay cn

li gi thng ng th (Hnh 9).

Hnh 9: p tim tr nh nhi : K thut 2 ngn tay

Tr nh:

Dng gt bn tay ca mt tay p ln xng c na di xng c,

nng cc ngn tay chc chn khng n vo xng sn tr, v tr ca bn

thng trc vi ngc a tr v cnh tay thng.

Tr ln:

Dng c hai tay vi cc ngn tay kho li vi nhau v p su t nht 1/3 b

dy lng ngc (Hnh 11).

Hnh 10: p tim tr nhi Hnh 11: p tim tr ln

43

Hi sc tim phi lin tc

Tn s p tim cho tt c cc la tui l 100 ln/pht, t l 15 ln

p tim : 2 ln thi ngt. Nu khng c s gip , phi lin lc vi trung

tm cp cu sau CPR 1 pht.

Phi cp cu c bn khng ngng cho n khi tr c c ng v th c.

p tim nn thc hin ng tc nhanh v mnh, su t nht 1/3

b dy lng ngc vi t l p tim 100 chu k/pht v hn ch ngng p

tim.

Khng cn kim tra li v tr p tim sau mi ln thng kh.

K thut hi sc tim phi cho tr nh nhi v tr nh c tm tt

trong Bng 1.

Bng 1: Tm tt cc k thut cp cu c bn tr em

Tr nh nhi v tr nh Tr ln

ng th

T th u nga Trung gian Nga u

Nhp th

Nhp th ban u 2 2

Tun hon

Bt mch Mch cnh tay hoc mch i ng mch cnh hoc

mch i

V tr p tim Na di xng c Na di xng c

K thut 2 ngn tay hoc 2 ngn ci

15/2

Mt hoc hai tay

T l p tim/thi ngt

S dng my chng rung t ng bn ngoi tr em

Trong 1 s trng hp c th dng my chng rung t ng bn ngoi

trong ngng tim tin pht v cng vi vic nhn vin c hun luyn c th

d dng s dng nhng ni cng cng nh sn bay, t hp thng mi.

44

T th hi phc

Tr nn c t t th m bo duy tr c thng thong ng th,

c th theo di v tip cn c v m bo an ton, lu cc im d b p.

Xc nh tui

Ch cn xc nh nhm tr nh (< 1 tui) v tr ln hn (t 1 tui tr ln).

T l p tim thng kh

Nu thi gian p tim di hn trong lc tin hnh cp cu th p lc ti

mu vnh s tng hn. T l p tim / thi ngt 15:2 l ph hp cho mi la tui .

Cc mc nhn vin cu h

Nhng ngi chng kin thng khng mun thc hin cp cu c bn

v h s lm sai v v lo lng khi phi tin hnh hi sc ming - ming vi

ngi l. Khi s dng ngi cu h trc tip, t l p tim/thng kh 30/2 c

khuyn dng c ngi ln v tr em. Khi c mt nhn vin y t cng c th

tin hnh vi t l ln 30 ln p 2 ln thi ngt cho tr em, nu h gp kh khn

khi chuyn t p tim sang thi ngt. Trong trng hp ngi cp cu khng th

tin hnh h hp nhn to ming ming h phi tin hnh p tim.

3. CP CU C BN V NGUY C NHIM TRNG

C t thng bo v bnh truyn nhim do thi ngt ming ming, nu

nhim no m cu, nn s dng khng sinh d phng cho ngi cp cu,

lao cng c th ly qua CPR v vy phi c bin php phng h. HIV, vim gan

B khng c thng bo ly truyn qua ng ming ming.

Cn thn trng khi tip xc vi cc cht nh mu, dch tit m o, dch

no tu, dch mng phi, dch mng bng v dch i, vi c nhng dch c th

cha mu. Gc hoc cc vt liu c l t trn ming nn nhn thng khng

c hiu qu trong trng hp ny.

D bp b dng thc hnh cha c biu hin l ngun ly nhim, v

sinh thng xuyn vn phi c tin hnh theo ch dn ca Nh sn xut. T

l nhim khun khc nhau tu theo tng nc nn ngi cp cu phi nhn

thc c nguy c ly nhim a phng mnh.

4. TR B D VT NG TH

Thng gp la tui tin hc ng, chn on him khi r rng, nghi

ng khi tr khi pht vi cc du hiu suy h hp t ngt, ho, nn o v th

rt. Phn bit vi vim np thanh mn v vim thanh qun.

45

Nhng tr b tc nghn ng th do nhim khun hoc nghi ng

nhim khun v nhng tr tc nghn khng r nguyn nhn nhng vn t th

cn c a ngay ti bnh vin.

Nhng phng php vt l lm thng ng th c m t sau y ch

nn tin hnh nu:

1. D vt ng th c chn on r (c chng kin hoc nghi ng

nhiu), tr khng ho c v kh th tng dn, mt thc hoc xut hin

ngng th.

2. T th nga u/nng cm v n hm lm thng ng th khng

c kt qu tr ngng th.

Nu tr ho c th nn khuyn khch tr ho. Khng nn can thip, tr

khi ho khng c hiu qu (ho yu) hoc a tr mt thc. Ho c hiu qu

c nhn ra bi cc du hiu : tr c th ni, khc hoc th gia nhng ln ho.

Tr vn tip tc c nh gi v khng nn tr mt mnh. Cc can thip ch

tin hnh khi tr ho khng hiu qu, tr khng th khc, ni, th hoc nu tr

tm v dn mt thc. Hy gi h tr v bt u cc can thip cho tr.

Hnh 12. Trnh t x tr mt tr sc

nh gi

Ho khng hiu qu Ho c hiu qu

Tnh Bt tnh

V lng 5 ln M thng

ng th

p ngc hoc

bng 5 ln

2 nhp thi

ngt

nh gi v tip

tc th thut

CPR 15 : 2

Kim tra d vt

Khuyn khch ho

H tr v tip tc

nh gi

46

Tr nh nhi

n bng tr nh nhi c th gy chn thng ni tng. V vy, la tui

ny nn phi hp ng tc v lng v n ngc loi b d vt.

t tr dc theo cnh tay ngi cp cu, u thp, ngi cp cu t tay

dc ln i mnh, bn tay gi vo cm tr gip cho ng th c m ra v

t tr t th trung gian v dng gt bn tay cn li v ln lng tr 5 ln.

Nu d vt khng bt ra, lt ngc tr li, t nm dc trn i vn t

th u thp. n ngc 5 ln ti v tr p tim vi tn sut 1 ln/giy. Nu tr qu

ln khng s dng c k thut 1 tay nh m t trn th t tr nm

ngang trn i ngi ngi cp cu v lm cng bin php. K thut ny c

m t Hnh 13 v Hnh 14.

Hnh 13: V lng tr nh nhi

Hnh 14 : n ngc tr nh nhi

47

Tr ln

S dng k thut v lng v n ngc nh tr nh nhi loi b d vt,

n bng c th gy ra chn thng bng.

Hnh 15: V lng tr nh

t tr nm nga, v tr n ngc tng t v tr p tim nhng t l mt ln

trong mt giy, tin hnh p tim

5 ln nu d vt vn khng ra c. Nu d vt ra c, nh gi cc du

hiu lm sng, c th vn c mt phn ca d vt cn li trong ng th. Mi

ln th nhn vo ming tr xem cn d vt hay khng v loi b d vt nu nhn

thy. Ch khng y d vt xung v trnh lm tn thng m mm. Nu d

vt c loi b , nhng nn nhn khng th vn tip tc thng kh h tr

hoc c thng kh v n ngc nu tr khng c du hiu ca s sng.

Nu tr th c hiu qu t tr t th hi phc v tip tc theo di nn

nhn.

Tr nh b hn m hoc tr ln c d vt ng th gy chn p

Ku h tr

t tr nm nga trn nn cng.

M ming a tr v th ly nhng d vt nhn thy c ra.

M thng ng th v th h hi thi ngt 2 ln, m thng li ng

th nu lng ngc khng di ng sau khi thi ngt.

Bt u p tim k c khi thi ngt khng c tc dng.

Tip tc tin hnh cp cu c bn trong 1 pht, sau gi h tr li

nu cha thy ai n.

48

H hi thi ngt li, xem li trong ming tr c d vt g nhn thy c

khng v ly d vt ra ngoi, cn cn trng khng y d vt vo su hn v

trnh lm tn thng m mm.

Khi gii thot c tc nghn d vt, nn nhn vn cn c thng

kh tip tc nu cha t th c hoc cn tin hnh ng thi c thng kh

v p tim nu cha thy du hiu hi phc ca tun hon.

Nu tr t th c, cho tr nm t th hi phc v tip tc theo di

tr.

49

5. TNG HP

D Nguy him?

R Hi : Chu c b sao khng

S Gi ngi h tr

A M thng ng th

B

Nhp th bnh thng ?

Thi ngt 2 ln

C

Kim tra mch

Khng qu 10 giy

Bt u CPR

15 p tim : 2 ln thi ngt

D

Kt ni my shock in

Chc chn gip ang n

Tip tc CPR cho n khi tr c p ng

Hoc nhp th bnh thng

Hnh 18. Ton cnh th t tin hnh cp cu c bn khi c ngng tim phi

50

TIP CN CHN ON V X TR BNH NHI KH TH

Kh th l biu hin thng gp trong cp cu nhi khoa, nguyn nhn gy

ra kh th gm 3 loi chnh: Kh th do tc nghn ng th, kh th do bnh

tim phi v kh th do bnh l ngoi tim phi (thn kinh, chuyn ho.). Cch

tip cn v x l chung trc mt bnh nhn kh th gm:

1.NH GI V CP CU BAN U

Vic nh gi v x l u tin theo th t A, B, C, D, E:

1.1.ng th: (A)

1.1.1. nh gi

S dng k nng: Nhn - Nghe - Cm nhn nh gi s thng thong

ng th: (Nhn: S di ng ca lng ngc, bng. Nghe: ting th v cm

nhn: hi th ca bnh nhn).

Nu tr cn c th ni c, khc c r, th ng th thng.

Nu lng ngc di ng km, khng c khng kh lu thng chng t ng

th tc hoc tr suy th nng.

Nu c ting rt thanh qun (Stridor) ngh n tc ng h hp trn.

1.1.2. X l

- Lm th thut m thng ng th: Nga u- nng cm hoc n- nng

gc hm.

- t canuyn ming - hng hoc mi hng.

- t ng ni kh qun (NKQ) nu cc x tr trn tht bi.

- Trong mt s trng hp cn thit c th phi chc catheter qua sn

nhn gip hoc m kh qun.

1.2. Th: (B)

1.2.1. nh gi: nh gi xem bnh nhn th c m bo khng da vo:

a. Th gng sc

- S co rt: y l du hiu thng gp trong kh th, khi c biu hin s

rt lm trn xng c th thng c tc nghn ca ng h hp trn.

- Tn s th: tng khi c kh th, nhng khi tn s th gim xung ri

chm li l du hiu nng ln.

51

- Ting th rt trong th th vo (Stridor) biu hin tc nghn ng h

hp trn, ting kh kh trong th th ra biu hin trong tc nghn ng h hp

di (hen, vin tiu ph qun).

- Th rn: thng gp trong kh th tr s sinh.

- S dng c h hp ph mi ln th.

- Cnh mi php phng.

- T th ca tr: khi b kh th tr thng tm mt t th thch hp lm

gim s kh th - nht l trong khi kh th do tc nghn (d tt, vim thanh

qun, hen, vim np thanh mn).

- Khi bnh nhn c biu hin kit sc, (gim s gng sc, tn s th gim,

gim thng kh hai phi) bo hiu bnh nhi ang trong tnh trng nguy kch.

a. Hiu qu ca th

- Nghe ting th: nh gi thng kh ca hai bn phi v ng th.

- S dn n ca lng ngc v di ng ca bng (nht l tr nh).

- bo ho oxy mch mu (s dng pulse oximeter)

- Biu hin phi cm (gim, mt r ro ph nang, di ng lng ngc gim

hoc khng di ng). bo ho oxy

52

- ny ca mch

- Thi gian tr v ca mu mao mch.

- Huyt p.

Khi huyt p h l du hiu nguy kch.

d. nh hng ca tun hon ln c quan khc

Nhp th v kiu th.

Mu sc da v thn nhit: Biu hin tm ti trung ng khng ci thin khi

cho bnh nhn th oxy lu lng cao l gi bnh nhn mc bnh tim bm sinh

c shunt phi tri.

Tnh trng tinh thn kinh

Lng bi niu

e. Du hiu suy tim: bnh nhn c th kh th do bnh ca tim c suy tim.

Tn s tim nhanh, c th c: nhp nga phi, nghe tim c ting thi.

Tnh mch c ni (t thy tr b m)

Nghe phi c ran m

Gan to

1.3.2 X tr

Tt c cc bnh nhn c biu hin suy tun hon (sc), cn phi c

cung cp oxy lu lng cao: (mi, mt n, ng ni kh qun).

Truyn dch hi phc khi lng tun hon (dung dch in gii hoc

dung dch cao phn t: 20ml/kg), tr trng hp bnh nhn c du hiu suy tim.

Ly mu lm mt s xt nghim cn thit: cng thc mu, in gii ,

ur, creatinin, nhm mu, kh mu, cy mu

1.4. Tinh, thn kinh: (D)

1.4.1. nh gi

nh gi tri gic ca bnh nhn da vo thang im AVPU (tnh - p

ng vi li ni - ch p ng vi au - khng p ng). Khi bnh nhn ch

p ng vi kch thch au, th cn thit phi c nhng bin php tr gip v

h hp.

Khm ng t: kch thc phn x.

Co git t th nm ca tr (khi b suy th tr thng t th gim trng

lc).

53

Khi bnh nhn c gim tri gic hoc c co git th bt buc phi nh

lng glucose mu.

1.4.2. X l

Bnh nhn b gim tri gic, khng hoc ch p ng vi kch thch au

cn phi t ng ni kh qun m bo s thng sut ca ng th.

Bnh nhn nghi ng gim glucose mu cn tim dung dch glucose 10%

hoc 20% vi liu lng 0,5g/kg (trc phi ly mu nh lng ng

mu).

S dng lorazepam tim tnh mch hoc diazepam bm, tht hu mn khi

bnh nhn b co git.

1.5 Khm ton thn: (E)

Ch ly nhit c th: nu st th gi tr c th b nhim khun (tuy

vy khi khng b st cng cha loi tr c nguyn nhn ny).

Pht hin ban trn da: nu l ban sn m ay phi nghi ng tr b

phn v.

2. CHN ON NGUYN NHN

ng thi vi vic nh gi v cp cu ban u cn phi hi bnh s ca

tr, t nht l trong 24 gi trc khi tr c cp cu. Kt hp vi kt qu cc

xt nghim c c, vic chn on nguyn nhn kh th c th da vo cc

triu chng dn ng theo s di y:

54

S 1. Chn on nguyn nhn kh th

Kh th do tc nghn

ng th

(Kh th chm)

Kh th th th vo km

ting rt (Stridor)

Kh th th th ra km

theo th kh kh

Kh th c hai th

Kh th + Hi chng xm

nhp

Kh th thanh qun

Kh th do ph qun (hen

ph qun)

Kh th kh qun

Kh th d vt ng th

Kh th do

Tim , phi

(Kh th

nhanh)

C suy

tim

Nhp tim nhanh Khng bt c

mch bn

Hp eo ng

mch ch

Tnh mch c ni Nhp tim rt

nhanh

Nhp nhanh

kch pht trn

tht Gan to Tim c ting phi,

tng gnh phi

Tim bm sinh c

shunt phi - tri

Tim to

(XQ)

Bnh cnh

nhim trng

Vim c tim

Khng c suy

tim, c biu hin

thng tn phi

v mng phi

Th kh kh ran lan

ta th th ra lng

ngc cng

Vim tiu

ph qun

Ran m nh

ht + st ()

Vim phi

G c vng thp, g

vang mt bn phi

Trn dch, trn

kh mng phi

Khng c du hiu tn

thng tim phi (tr

ng ng th )

C du hiu thn kinh

km theo

Lit h hp

Lng ngc bin dng D dng lng ngc

Kh th do

ngoi Tim ,

phi (khng

c du hiu

gng sc)

Tng thng kh

Try mch

Thiu mu

Chy mu Thiu mu cp

St cao Du hiu

nhim trng

Nhim khun mu

Nhim khun nng

Mt nc a chy

cp Vim d dy rut

i nhiu,

tng ng

huyt

i tho ng,

nhim toan

Nhim toan

n thun

Ng c cp (Salicylat)

Bnh chuyn ha (t gp)

Gim thng

kh

Ri lon

tri gic

Du hiu

thn kinh

Nguyn nhn

trung ng

Chn thng s

no Trng thi ng kinh

Tn thng h thn

kinh TW

Ng c

Ngt th, du hiu kit sc

55

3. NH GI LI V IU TR CP CU THEO NGUYN NHN

Sau bc cp cu v nh gi ban u, tnh trng bnh nhn tm n nh,

nguyn nhn kh th c xc nh (da vo cc triu chng dn ng xem

s 1). Bnh nhn cn phi c khm, nh gi li t m hn. Lc ny mt s

xt nghim mu, cn lm sng (X- quang, in tm , kh mu) cn c

lm thm gip cho vic chn on, iu tr v theo di bnh nhn theo

nguyn nhn.Tuy vy, trong giai on ny bnh nhi vn lun c gim st cc

chc nng sng (h hp, tun hon, tinh thn kinh, thn nhit) nu c ri lon

no th phi tin hnh nh gi v iu tr cp cu ban u li.

3.1 iu tr cp cu

- Nu nghe thy c lc xc trong ming bnh nhn: ng th c

nhiu cht dch tit, i hi phi ht sch.

- Nu bnh nhn c th rt thanh qun (Stridor) km vi ting ho ng

ng v biu hin suy th nng th chng t ng h hp trn b tc nghn c

th do vim thanh qun nng, cn phi cho bnh nhn th kh dung adrenalin

(5ml adrenalin 1:1000 ).

- Nu bnh nhn c ting th rt thanh qun nh nhng tnh trng chung

ca tr rt nng (st, suy th, tit nhiu nc bt) c kh nng tr b vim np

thanh qun cn: cho khng sinh, corticoid v mi ngi c kinh nghim t ng

ni kh qun cp cu. Tn trng t th thch nghi ca tr, khng lm cho tr s

hi.

- Din bin bnh t ngt, c tin s ca hi chng xm nhp phi ngh

n nguyn nhn d vt thanh qun. Nu s dng quy trnh x l i vi tr b

sc khng thnh cng th phi tnh n vic ni soi thanh qun cp cu.

- Th rt thanh qun xy ra ngay sau ung hoc tim thuc phi ngh n

nguyn nhn phn v. Tim bp adrenalin 10g/kg.

Bnh nhn c tin s hen ph qun hoc th kh kh c suy th nng -

lu lng nh gim v/hoc thiu oxy th cho kh dung ventolin v Ipratropium

vi oxy. tr b m c th do vim tiu ph qun th ch cn th oxy.

3.2. iu tr n nh tnh trng v vn chuyn an ton bnh nhn

Sau bc iu tr cp cu, tnh trng bnh nhn tm n nh vn phi

thng xuyn gim st nh gi bnh nhn, vic quyt nh tip theo (chuyn

hi sc tch cc, chuyn iu tr chuyn khoa hay chuyn vin) ph thuc vo

56

tnh trng bnh nhn v iu kin ca c s y t tip nhn bnh nhn ban u.

Trn nguyn tc khi chuyn bnh nhn phi an ton, m bo ba yu t an ton

ca bnh nhn: bnh nhn phi c n nh chc nng sng (ng th, th,

tun hon), lin h cht ch vi ni bnh nhn s chuyn n, tip tc duy tr

chc nng sng ca bnh nhn trong sut qu trnh vn chuyn (Xem bi vn

chuyn an ton bnh nhn).

NGNG TH NGNG TIM

1. I CNG

tr em ngng th thng l hu qu ca tnh trng suy h hp cp.

Ngng tim thng sau ngng th.

No s b tn thng khi ngng th ngng tim trn 4 pht v nu trn 10

pht thng t vong, nu sng s li di chng no nng n. V th khi ngng

th ngng tim cn nhanh chng cung cp oxy v mu cho no.

C 2 loi hi sc:

Hi sc c bn: hi sc ti hin trng, khng c dng c

Hi sc tin b: hi sc thc hin ti c s y t hoc trn xe cu thng

vi dng c, thuc cp cu

2. HI SC C BN

2.1 Chn on ngng th ngng tim

- Hn m: lay gi khng tnh

- Lng ngc khng di ng

- Khng c mch trung tm

2.2 Hi sc c bn

Thc hin ti ni xy ra tai nn ngoi bnh vin

Nguyn tc: nhanh v theo th t A, B, C

Thng ng th (Airway)

Thi ngt (Breathing)

n tim ngoi lng ngc (Circulation)

Cc bc thc hin theo th t u tin:

57

a. Lay gi, ku gip

- Lay gi bnh nhn

- Nu khng p ng l hn m, nghi ng ngng th ngng tim khi hn m

v ku gi ngi gip

b. Thng ng th

- Nga u nng cm, nu nghi chn thng ct sng c th dng phng

php n hm v c nh c trnh di lch ct sng c

Trong trng hp hn m th cc c vng c mt trng lc gy chn p

tc ng th

- Ly d vt nu c:

+ Th thut v lng n ngc: s sinh, nh nhi

+ Th thut v lng: tr ln

Khng dng tay mc m d vt v c th y d vt vo su hn v lm

tn thng nim mc ming hu

c. Quan st di ng lng ngc v nghe cm nhn hi th

- Lng ngc khng di ng

- Khng cm nhn c hi th BN

d. Thi ngt

- Thi ngt 5 ln t c 2 nhp c hiu qu

Thi c hiu qu khi thy lng ngc nh ln khi thi

e. Bt mch trung tm

- S sinh, tr nh: mch cnh tay, mch bn

- Tr ln: mch c, mch bn

Nu c mch trung tm th tip tc thi ngt

Khng c mch trung tm trong vng 10 giy Ngng tim n tim

ngoi lng ngc.

f. n tim ngoi lng ngc

- V tr n tim cho mi la tui: di xng c

- n su 1/3 b dy lng ngc

- Tr s sinh nh nhi (di 1 tui):

- K thut: 2 ngn ci hoc 2 ngn tay

Ngng th

58

Hnh 1: n tim 2 ngn tay

- Tr ln (Trn 1 tui):

- K thut: 1 bn tay ( 1- 8 tui)

2 bn tay (> 8 tui)

Hnh 2: n tim 1 bn tay

Tn s n tim cho tt c cc la tui: 100 ln/pht

n tim ng: mch trung tm c khi n

- Ngng th ngng tim:

T l n tim/ thi ngt: 15/2 cho 2 cp cu vin, 30/2 cho 1 cp cu vin

3. HI SC NNG CAO

Thc hin ti c s y t, bnh vin c y dng c v thuc cp cu

3.1. Lay gi, ku gip

- Lay gi bnh nhn

- Nu khng p ng, hn m, ku gi BS, D gip

3.2. Thng ng th:

- Nga u nng cm (nghi chn thng ct sng c: n hm, c nh c )

- Ht m

- Ly d vt nu c:

+ Th thut v lng n ngc: s sinh, nh nhi

+ Th thut v lng: tr ln

- t ng thng ming hu khi tht bi vi nga u, ht m

59

3.3. Quan st di ng lng ngc v cm nhn hi th

- Lng ngc khng di ng

- Khng cm nhn c hi th BN

3.4. Bp bng qua mask

- Bp bng qua mask 2 nhp c hiu qu vi FiO2 100%

Bp bng c hiu qu: lng ngc nh khi bp

- Bp bng m lng ngc khng nh:

+ ng th cha thng: kim tra nga u

+ Mt n khng kn

+ C bng nh so vi tr

+ Bp bng nh tay

- n nh sn nhn (th thut Sellick): trnh hi vo d dy, gim chng

bng v nguy c ht sc

3.5. Bt mch trung tm

Khng c mch trung tm trong vng 10 giy Ngng tim

3.6. n tim ngoi lng ngc

K thut n tim: xem phn hi sc c bn

T l n tim/ bp bng

- S sinh : 3/1

- Tr ngoi tui s sinh : 15/2

Nu c 2 ngi: ngi n tim m ln ngi bp bng nghe phi hp

Tip tc bp bng v n tim trong vng 2 pht, sau nh gi li

Trng hp khng t th li sau bp bng qua mask (1 - 5 pht): t ni

kh qun ng ming v bp bng qua NKQ

3.7. Thuc

Thit lp ng tnh mch. Nu sau 2 ln ly ven ngoi bin tht bi phi

tin hnh tim trong xng (dng kim 18 vi trocha, bm tim 5ml, tim vo

mt trc, 2-3 cm di mo xng chy).

- Epinephrine (Adrenaline) 1 TM

Ch nh: ngng tim

Cch pha dd Epinephrine 1: dng ng tim 10 ml rt 1ml dd Epinephrine

1 + 9 ml nc ct.

Ngng th

60

Liu: 0,1 ml/kg dung dch 1%oo TM. Sau khi bm Epinephrine, bm 2 5

ml nc mui sinh l y thuc.

Sau 3 - 5 pht tim cha p li: lp li liu hai nh trn hoc gp 10 ln,

nhc li mi 3 5 pht.

- Epinephrine (Adrenaline) 1 bm qua NKQ, dng trong trng hp

khng c ng tnh mch

Liu: 0,1 ml/kg dung dch Epinephrine 1 pha NaCl 9 cho 1-2 ml.

Sau bm NKQ: bp bng thuc phn tn v hp thu vo h tun hon -

Bicarbonate u trng:

- Khng thng quy v nguy c CO2 gy nng thm tnh trng toan h hp.

- Ch nh:

Toan chuyn ha nng,

Nu khng th kh mu c : c th xem xt ch nh Bicarbonate sau 10

pht bp bng gip th v tim Epinephrine bnh nhn vn cn ngng th

ngng tim.

- Liu: dung dch bicarbonate 8,4% 1ml/kg/ln hay dung dch 4,2% 2

ml/kg/ln TMC, khng c dng chung vi ng TM ang truyn canxi.

- Atropine

Ch nh: nhp tim chm (nhp chm xoang).

Liu: 0,02 mg/kg TMC, liu ti thiu 0,1 mg, ti a 0,5 mg/liu hoc tng

liu khng qu 1mg.

- Amiodarone

Ch nh: y l thuc c la chn trong trng hp nhp nhanh trn

tht, rung tht, nhp nhanh tht mt mch.

Liu 5 mg/kg bm TM nhanh hay qua tu xng trong 20 - 60 pht.

C th nhc li liu trn. Liu ti a 15 mg/kg/ngy. Theo di huyt p

trong qu trnh iu tr v thuc gy tt huyt p nu tim nhanh.

Thuc thay th: Lidocain 2% (0,04g / 2ml), liu 1mg/kg TM, duy tr 20-

50 g/kg/pht qua bm tim t ng.

- Canxi: khng dng thng qui, ch dng trong trng hp c bng

chng h can xi huyt hoc ng c thuc c ch canxi.

Calcium chloride 10% 0,2ml/kg TM chm

Calcium gluconate 10% 1ml/kg TM chm

- Glucose:

61

Ch nh: h ng huyt (Dextrostix)

Tr ln: dung dch glucose 30% 2ml/kg TMC

Tr s sinh : dung dch glucose 10% 2ml/kg TMC

- Truyn dch:

Nu nguyn nhn ngng th ngng tim l hu qu ca sc gim th tch:

truyn nhanh Lactate Ringer 20 ml/kg/15 pht, nu tht bi dng dung dch cao

phn t.

Trong trng hp cp cu khng th cn bnh nhn c c th c

lng cn nng theo tui:

- Tr 0-12 thng : Cn nng(kg) = (0,5 x tui tnh theo thng) + 4

- Tr 1-5 tui : Cn nng(kg) = (2 x tui tnh theo nm) + 8

- Tr 6-12 tui : Cn nng(kg) = (3 x tui tnh theo nm) + 7

3.8. Sc in (xem lu x tr ngng th ngng tim sau bp bng n tim)

Ch nh:

- Sc in khng ng b: Rung tht, ngng tim, nhp nhanh tht mt

mch.

- Sc in ng b: nhp nhanh tht c mch, nhp nhanh kch pht trn

tht, sau khi iu tr thuc tht bi hay c ri lon huyt ng.

tr nh, dng bn in c tr em 4 5 cm. Nu khng c bn nh, c

th dng bn ln t trc v sau ngc.

Sau mi ln sc in, phi nghe tim v theo di nhp tim qua monitor

c hng x tr tip

3.9. Theo di sau hi sc

- Nhp th, mu da, nim mc, mch, HA, tri gic, ng t mi 15 pht

- SaO2 ( bo ha oxygen)

- Nhp tim bng ECG monitoring,

- Kh mu, ion , Dextrostix, XQ tim phi

- Din tin tt: hng ho, t th, tim p li, mch r, tnh to.

- Khi no ngng hi sc ?

Quyt nh thi im no ngng hi sc trng hp ngng th ngng tim

ko di th kh khn. Tuy nhin c th xem xt vic ngng hi sc nu sau 30 -

60 pht m tim khng p li, khng th li, ng t dn v sau khi gii thch

thn nhn.

62

CC BC TIN HNH CP CU NGNG TIM

nh gi

nhp

Sc in: Rung tht,

nhanh tht mt mch

Khng sc: ngng

tim, mt mch cn

in tim

Nguy him ?

Hi: "Chu c b sao khng"

Gi ngi h tr

M thng ng th

Nhp th bnh thng? Thi ngt 2 ln

Kim tra mch

Khng qu 10 giy

Bt u CPR

15 p tim: 2 ln thi ngt

Kt ni my shock in

Chc chn gip ang n

63

LU IU TR RUNG THT V NHP NHANH THT

MT MCH

Trong qu trnh CPR

Dng c ng th (LMA/ETT)

Oxy

Dng c o CO2

Thit lp tun hon

K hoch hnh ng trc khi

ngng n tim (sc my sc 4J/kg)

Tm nguyn nhn:

Thiu Oxy

Gim th tch

Tng/h kali, ri lon chuyn ho

Tng gim nhit

Trn kh mng phi

Chn p tim cp

Ng c

Huyt khi ( phi/mch vnh)

Chm sc sau hi sc: nh gi li ABCDE

Lm in tm 12 chuyn o

iu tr nguyn nhn

nh gi li Oxy v thng kh

Kim sot nhit

nh gi

nhp tim

Sc in

VF/VT mt

mch

Khng sc in

PEA/v tm

thu

Tun

hon

tr li ?

Chm sc sau hi sc

Bt u CPR

Kt ni my sc in/my theo di

Sc in (4J/kg)

khng ng b

Adrenaline

10mcg/kg

Sau ln sc th 2

(sau mi 2 chu k)

Amiodarone

5mg/kg

Sau ln sc th 3

CPR

Trong 2 pht

CPR

Trong 2 pht

Adrenaline

10mcg/kg (sau

mi 2 chu k)

64

LU X TR NHP TIM CHM

v

C sc?

iu tr thiu Oxy

v sc

Adrenalin

10mcg/kg

Khng

C sc?

Mi hi chn

Atropin 20mcg/kg

kch thch

ph v?

Khng

m

Cn nhc Adrenaline TM

hoc t my to nhp

Khng

C

C

sc?

Khng C

65

LU X TR NHP NHANH KCH PHT TRN THT

*Liu ti a 12mg(s sinh 300mcg/kg)

C sc?

Nghim php kch

thch TK ph v (nu

iu kin cho php)

Nghim php kch

thch TK ph v

Thit lp ng

truyn nhanh

hn sc in?

Khng C

Adenosine

100mcg/kg

Adenosine

200mcg/kg

Cn nhc

Adenosine 400-500 mcg/kg*

Sc in ng th

Hoc Amidarone

Hoc thuc chng lon nhp

khc (xem ch dn)

Adenosine

300mcg/kg

Sc in ng th

liu 2J/kg

Sc in ng th

liu 1J/kg

Khng

Cn nhc Amiodarone

C

66

LU IU TR NHP NHANH THT

C mch? iu tr theo phc

rung tht

Amiodarone 5mg/kg trn

30 pht

C

C sc?

Sc in 2J/kg

Sc in 1J/kg

ng b

Cn nhc sc in ng b.

Mi hi chn

Amiodarone

C Khng

67

VN CHUYN AN TON BNH NHN TR EM

Vic vn chuyn bnh nhn t khoa ny n khoa khc trong cng mt

bnh vin hoc t bnh vin ny n cc bnh vin khc khng c tnh

trng ca bnh nhn nng thm ln, v vy vn chuyn bnh nhn i hi c ch

nh ng, vic chun b v thc hin theo ng mt quy trnh nh sn v do

nhng ngi c kinh nghim thc hin. Mc tiu l m bo ti u s an ton

ca bnh nhn trong sut qu trnh vn chuyn vi vic theo di st tnh trng

bnh v c nhng bin pht x tr thch hp.

1.CH NH

Vic chuyn bnh nhn c thc hin khi tnh trng bnh nhn i hi

phi chuyn n ni c iu kin chm sc, iu tr, theo di c tt hn hoc

n ni lm cc thm d, xt nghim phc v cho vic chn on v iu tr

bnh nhn.

2. T CHC

- Ngi c kinh nghim v c o to vn chuyn bnh nhn.

+ Gii thch cho b m, ngi nh bnh nhn l do chuyn bnh nhn.

+ Khm, nh gi nhanh tnh trng bnh nhn.

- Lin h bng in thoi trc tip vi ngi c trch nhim (chuyn mn)

ni m bnh nhn s c chuyn n.

m bo an ton bnh nhn cn:

- Khng nh li ch nh chuyn bnh nhn.

- Xc nh ni bnh nhn s chuyn n.

- Quyt nh nhng can thip cn thit trong khi ch i.

- D kin phng tin vn chuyn, dng c cp cu cn thit v ngi

trc tip vn chuyn bnh nhn cng nh thi gian xut pht v n ni.

- Trong qu trnh vn chuyn trn ng cn c s lin h cht ch vi

ni xut pht v ni s n qua in thoi.

3. PHNG TIN VN CHUYN BNH NHN

- Xe vn chuyn bnh nhn chuyn dng (c cng vn chuyn, c lng

m vi tr s sinh).

- Trang b ti khoa Cp cu v c s dng c, thuc men y theo

di v iu tr cho bnh nhn trong khi c vn chuyn (tt c nhng nhn vin

h tng phi nm r).

68

3.1. Phng tin cp cu bnh nhi

3.1.1. ng th

- Canuyn ng th cc c: 000, 00, 0, 1, 2, 3.

- ng ni kh qun cc c t: 2,5 7,5mm (ng 7,5mm c bng chn

cuffed).

- n t ng NKQ

+ Li thng: cho s sinh, tr nh.

+ Li cong: cho tr ln.

- Km gp Magill

- My ht xch tay (Yankauer).

- ng ht mm.

- Kim chc d qua sn nhn gip.

3.1.2. Th

- My th.

- Bnh cha oxy (mini) c van iu chnh p lc. Bnh nn c E, cha

600l, c th cho th trong 150 pht vi lu lng 4l/pht.

- Mt n th oxy c ti d tr.

- Bng bp t phng c ti d tr vi cc kch thc (240ml cho tr b

m, 500ml cho tr nh/1600ml cho tr ln).

- Mt n cc c:

+ Cho tr b m : 0, 1, 2

+ Cho tr nh : 2, 3

+ Cho tr ln : 4, 5

- ng ht thng ming v b phn ni.

- Bng bp (ayrs T - piece).

- B dn lu mng phi.

3.1.3. Tun hon

- My kh rung (sc in) c gn gim st in tim cho tr em.

- My o huyt p (cc c bng cho tr em).

- My o nng oxy mch mu (pules oximeter).

- Dng c thit lp ng truyn.

69

+ ng thng tnh mch.

+ Kim truyn trong xng (c 16- 18).

- Dy truyn c bu m.

- Bm tim: 1- 50ml.

- My m git.

- My tim (rt cn cho bnh nhn vn chuyn ng xa).

- Dng c bc l tnh mch.

3.1.4. Dch truyn

- Dung dch mui ng trng NaCl 0,9%.

- Dung dch ringerlactat.

- Dung dch glucose 5%, 10%.

- Dung dch hn hp: (Glucose 4% v natriclorua 0,18%).

- Dung dch keo.

- Dung dch albumin 4,5%.

3.1.5. Thuc

- Epinephrin (Adrenaline) 1:10.000, 1:1000

- Atropin sulfat 0,25mg

- Natribicarbonate 8,4%, 4,2%

- Dopamin 40 mg/ml

- Dobutamin

- Lignocain 1%

- Amiodaron

- Calcium clorid 10%, calcium gluconat

- Furosemid 20mg/ml

- Manitol 10%, 20%

- Valium 5mg, 10mg

- Khng sinh: cefotaxim, gentamicin, penicillin, ampicillin

3.2. Phng tin khc

- My glucose k

70

Vi phng tin trang b nht thit trn ng vn chuyn phi gim

st:

- in tim, tn s tim

- bo ha oxy

- Huyt p

- Nhit (trung tm / ngoi vi)

- CO2 ca kh th cui th th ra ( End tidal CO2)

- Tn s th

Cc trang thit b c trang b ni d ly v thng xuyn phi c

kim tra, b sung sau mi ln vn chuyn bnh nhn. Ngun in cho my (pin,

c quy) cng phi c sc b sung thng xuyn.

4. VN CHUYN

Lun m bo ng th v th trong qu trnh vn chuyn.

Vi bnh nhn chn thng hoc bnh nng cn phi m bo ng th

v thng kh h tr:

- t ng ni kh qun (NKQ)

- Bp bng qua ng NKQ vi oxy hoc th my (nu c iu kin).

- Ch an thn tt cho bnh nhn v c nh chc ng NKQ (tt nht l

t ng qua ng mi khi bnh nhn c ri lon ng mu hoc tn thng nn

s).

4.1.m bo chc nng tun hon

m bo c hai ng truyn tt trong qu trnh vn chuyn nht l i

vi bnh nhi c nguy c ri lon tun hon (sc) qua y c th truyn cc

dch keo, dung dch gy kch ng mch mnh (bicarbonat, kali, calcium,

adrenalin) vo tun hon trung ng (tt nht l c c mt ng truyn

vo tnh mch trung tm).

4.2. Tinh thn kinh

Vn chuyn bnh nhn hn m i hi phi cn nhc c bit vi nhng

bnh nhn b chn thng, trnh tai bin th pht ca h thn kinh trung ng.

4.3. Thn nhit

Bnh nhi d b nhim lnh nht l tr nh, tr s sinh cho nn trong khi

vn chuyn khng c tr b h thn nhit (c th s dng chn, bnh nc

lm m, h thng iu ha m trn xe) lm m bnh nhn. Nn s dng

71

phng php Kangaroo m cho tr nh. Dch truyn cn phi c m

trc khi truyn cho tr.

Trong qu trnh vn chuyn nu pht hin ra bt c biu hin nng no

u phi c x l kp thi.

4.4. Ghi chp h s bnh n

- Tt c cc th thut, thuc, dch truyn cho bnh nhn phi ghi chp .

- Cc du hiu lm sng, cc xt nghim, X quang, nhm muphi

thng bo cho ni bnh nhn s chuyn ti (nu c iu kin thng bo trc

qua in thoi).

4.5. Chun b bnh nhn trc khi vn chuyn

- Ch thc hin vn chuyn bnh nhn khi cc chc nng sng phi m

bo v duy tr tt (ng th - tun hon thn nhit pH, ng mu).

- Cc vic sau y cn lm chun b tt, an ton cho vic chuyn bnh

nhn:

1. Xem ng th v th m bo cha? (kh mu ng mch nu c

th).

2. c nh c, tay, chn ca bnh nhi tt cha?

3. Oxy mang i theo cha?

4. ng truyn tnh mch cho bnh nhn tt cha?

5. cc loi dch cho bnh nhn trong khi vn chuyn cha?

6. Cc phng tin gim st bnh nhn.

7. Liu bnh nhn c m trong qu trnh vn chuyn hay khng?

8. H s, bnh n cha?

- H tn bnh nhn

- Tui

- Cn nng

- Phim chp X quang nu c

- Triu chng lm sng

- Thuc s dng (liu, ng dng, thi gian)

- Theo di dch truyn

- Ch s h hp (nhp th, kiu th ca bnh nhn, ca my th).

- Cc kt qu xt nghim

72

9. trao i vi ni nhn bnh nhn cha?

10. trao i vi b m, ngi nh ca bnh nhn cha?

4.6. Mt s trng hp c bit

- Bnh nhn s sinh b teo thc qun: cn tr t th ngi u nghing

phi t ng thng vo khoang ti cng ht nhiu ln (ch trnh lm tn

thng). C th ch ng t ng ni kh qun ht thng ni kh qun, trnh

bp bng h hp nhn to.

- Thot v c honh: cn t ng NKQ (khng c bp bng qua mt n)

h hp h tr qua ng NKQ vi tn s nhanh v p lc thp hn bnh thng,

t ng thng d dy ht cht dch ng.

- Bnh nhn s sinh b thot v rn hoc thot v qua khe h thnh bng

th bc cc quai rut v ph tng trong mt tm gc v khun bnh nhn

nghing v mt bn. Trong qu trnh vn chuyn phi lin tc lm m v lm m

khi thot v.

- Nhng trng hp: tr s sinh b thot v mng no ty th tr nm

sp trong khi khi thot v v vng b thng tn c che ph mt tm

gch v khun v c lm m, m trong qu trnh vn chuyn.

- Tt c tr s sinh c chuyn n ni can thip ngoi khoa u phi

c tim bp 5mg vitamin K1.

- Tr s sinh ca nhng b m b i tho ng, phi c truyn dung

dch glucose 10% trong sut qu trnh vn chuyn.

- i vi tr b vim np thanh qun hoc tc nghn ng h hp, khi

vn chuyn phi t th ngi hoc nm nghing sang mt bn.

- Vi bnh nhn sc nhim khun, c bit nhim khun do mng no cu

c ban xut huyt hoi t lan ta th khng c vn chuyn khi tr cn b sc

v nhit >39oC.

73

NGUYN TC TIP CN V X L NG C CP TR EM

tr em, ng c xy ra nh l 1 tai nn khng c , c bit tr em

di 12 tui, ch yu xy ra qua ng tiu ho (do n ung phi cht c).

1. CHN ON

1.1. Trc mt tr nghi ng c cp cn xc nh.

- Tr c b ng c tht s hay do mt nguyn nhn bnh l khc

- Mc nng ca ng c.

- Cht c l g.

- Thi gian b ng c, lng cht c m tr n ung phi.

1.2 Trong thc t cc tnh hung c th xy ra l.

- D chn on: gia nh a tr n vi li khai r rng cc tang chng

a theo c th (thuc, chai l ng thuc, c, qu)

- Kh chn on: phi da vo nhiu yu t (hi bnh, khm lm sng v

xt nghim c cht), c th nghi ngh tr b ng c khi:

+ Cc triu chng bt thng xy ra t ngt (hn m, co git, nn, tiu

chy, tm ti) tr trc hon ton kho mnh hoc ch nhng bnh nh

thng thng (st nh, ht hi, s mi)

+ Thng khng st cao (ngoi tr mt s cht c nht nh).

+ Hi nhng ngi xung quanh (i theo) v cc cht c (thuc dit

chut, thuc tr su) hoc thuc iu tr m gia nh hin ang dng.

1.3. Khm lm sng ton din:

xc nh tnh trng ca tr, c bit phi ch xc nh c: tui,

cn nng, cc chc nng sng nh h hp, tun hon, tinh thn kinh, thn nhit).

ng thi pht hin cc du hiu ch im c hiu, v d:

- Hn m, khng c du hiu thn kinh khu tr km theo: ng c thuc

ng (barbituric) hoc cc loi an thn khc.

- Co git: Ng c strychnine, atropin, theophylin, long no

- Co ng t: Ng c atropin, imipramin, thuc m, ru

- Mch chm: Ng c digitalis, quinine, muscarin

- Mch nhanh: Ng c atropine, xanthin, theophylin

74

- St cao: Ng c nhm xanthin, theophylin

- H thn nhit: Ng c barbituric,phenothiazin

- Tng thng kh: Ng c salicylat (aspirin)

- Xut huyt: Ng c cht chng vitamin K

1.4. Xt nghim c cht:

Phi ly cc cht nn, dch d dy, phn, nc tiu, mu ca bnh nhn v

cc cht vt phm nghi ng m gia nh a n xc nh c cht.

1.5. Tu theo mc nng nh v cc ri lon m mt s xt nghim sau y

cn phi lm gip cho vic theo di v iu tr:

Cng thc mu, ur, creatinin mu, in gii , ng mu, kh mu,

chc nng gan, in tm

2. X L

2.1. m bo v duy tr cc chc nng sng

- Phi m bo bnh nhn th tt: lm thng ng th, th oxy, t ng

ni kh qun, h hp h tr nu cn.

- m bo chc nng tun hon: cp cu ngng tim (nu c). Nu bnh

nhn c biu hin sc th phi truyn nhanh dung dch c in gii, dung dch

keo hoc mu (tu theo trng hp c th, khng c dng ngay thuc vn

mch nu cha c truyn dch tha ng.

- iu tr v ngn nga co git hay ri lon thn nhit.

2.2. Loi tr cht c

2.2.1. Nhng cht c qua da, nim mc

- Ci b qun o.

- Ra sch c th bng nc hoc dung mi thch hp.

2.2.2. Nhng cht c qua ng ung: Cc bin php loi b cht c l:

Gy nn, ra d dy, ty rut, bi niu mnh, lc mu ngoi thn (thm

phn phc mc, thn nhn to), h hp h tr.

a. Gy nn, ra d dy

- Gy nn: Ch nh khi cht c dng thc n, l, thuc vin, thc hin

trong vng mt gi u sau khi tr n ung phi cht c m vn cn tnh to.

+ C th lm tc khc bng cch cho ngn tay vo hng kch thch

nn.

75

+ Ung sir Ipeca 7- 10%: tr em 6 - 12 thng ung 1 ln 10ml, 1-10 tui

ung 15ml, trn 10 tui ung 30ml. Sau khi ung xong cho tr ung nhiu nc,

nu sau 20 pht tr khng nn th ung liu th hai.

+ Tim apomorphin liu 0.07mg/kg sau 2 n 5 pht tr s t nn (nu c

du hiu suy th th tim naloxon (Narcan) liu 0.01mg/kg.

- Ra d dy

+ Ch thc hin trong 6 gi u sau khi ung phi cht c v tr vn

cn tnh to hoc c t ng ni kh qun nu tr b hn m.

+ t ng thng vo d dy, cho bnh nhn nm u hi thp nghing v

mt bn. Dng nc m thm natriclorua (1 lt nc thm 4g natriclorua) hoc

dng lun dung dch huyt thanh mn ng trng 0.9% ra v lm sch d

dy. Phi ch cht dch chy ra xem c cc mu thuc, thc n, mu. V

nguyn tc l ra cho n bao gi nc ly ra trong (thc t l lng dch ra

d dy khong 100ml/kg cn nng tr em. Cht dch thu c cn gi i xt

nghim c cht. Sau khi ra xong nn bm than hot vo d dy.

- Chng ch nh gy nn v ra d dy:

Khng gy nn v ra d dy khi bnh nhn ang co git v hn m.

Cht c l cht n mn (acid, kim, thuc ty), cht bay hi (xng, du

ho, nc hoa), cht du khng tan (cht bi trn, cht lm bong).

b. Than hot:

Ly khong 30gam than hot pha vi nc thnh 1 th h, liu dng

1g/kg cn nng cho 1 ln. Cho bnh nhn ung trc tip hoc bm vo d dy

sau khi ra d dy, c hiu qu tt nht mt gi u sau khi bnh nhn n, ung

phi cht c. Than hot khng c hiu qu i vi cc cht c l: ru, acid

boric, st, alcan, thilium, mui acid, cyanid, cc cht c hydrocarbon.

c. Thuc ty rut:

S dng mag sulphat 250mg/kg cn nng hoc du paraphin 5ml/kg cn

nng, Khi dng thuc ty phi theo di tnh trng mt nc, in gii. Khng

dng thuc ty c magi cho ngi c suy thn.

d. Tanin:

Lm bin tnh mt s alcaloid v c th kt hp vi mui kim loi nng,

ngn cn s hp thu ca chng. Liu dng 2-4g/ mt ln.

e. Bi niu mnh:

Ch nh khi cht c c o thi qua thn.

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f. Kim ho mu: ng c thuc ng Barbiturate

g. Lc mu ngoi thn:

Ch nh trong nhng trng hp ng c nng vi lng ln cc cht

c c kh nng qua c mng lc.

h. o thi cht c qua ng h hp:

- Ch nh trong nhng trng hp ng c cht bay hi (Ru, benzene,

ether,ceton, oxydcarbon, xylem)

- K thut: t ng ni kh qun, h hp h tr.

2.3. Gii c

- Gii c khng c hiu:

+ Hp th: than hot, tanin, sa.

+ Trung ho ho hc: dng oxyd magi trung ho acid, dng dm pha

long, chanh trung ho cht kim

- Gii c c hiu:

- Ch dng khi bit chc chn cht gy c v ch pht huy ht tc dng

khi cht c cn lu thng trong h tun hon.

V d: Methemoglobin Dng xanh methylen

Opi Narcan

Phospho hu c Conthrathiol + Atropin

Paracetamol N. Acetyl systein

Heparin Protamin

Dicoumarin Vitamin K1,PPSB

77

X TR VT THNG DO NGI V SC VT CN

Cc vt thng do ngi v sc vt cn chim khong 1% s cc trng

hp n khoa cp cu, trong ch yu do ch cn (80-90%) sau y do mo,

kh chut v ngi. Tr trai thng b cn nhiu hn tr gi v ch yu xy ra

vo ma h. Do tnh thng gp v nhng bin chng tim n ca nhng vt

thng loi ny, ngi thy thuc cc c s cp cu cn phi nm vng cch

tip cn v x l chng.

1.TIP CN CHN ON

1.1 Hi bnh s bit c

- Loi sc vt no hay ngi cn, trong hon cnh no.

- Thi gian b cn.

- Tin s bnh ca tr trc (i tho ng, bnh mch mu ngoi vi,

bnh nhim khun, bnh mn tnh ang s dng steroid hoc cc bnh gy suy

gim min dch khc).

1.2 Khm ni khoa ton din

- Khm ton din xc nh tnh trng chung ca tr (ng th, th,

tun hon, tinh thn kinh)

- Khm k vt thng bit: V tr, kiu tn thng (vt rch, bm dp

do day nghin, vt cn ngp su do rng), tr em vt cn vng u c

th gy tn thng xng s, nhng tn thng vng khp d nh hng n

hot ng ca khp .

Ch n cc du hiu nhim khun: ban xut huyt, sng ty, cht dch,

m chy ra t vt thng, phn ng hch, au cc chi lin quan khi th ng.

1.3. Cc xt ng